Cassidy, Merkley Introduce Bill to Better Assess Medicare Patient Health, Avoid Overpayments

Published 12:30 pm Tuesday, March 28, 2023

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WASHINGTON – U.S. Senators Bill Cassidy, M.D. (R-LA) and Jeff Merkley (D-OR) today introduced a bill to improve the way Medicare Advantage plans assess patients’ health risks and reduce overpayments for care. The No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act will save taxpayers billions by eliminating incentives to overcharge Medicare for care.


“Medicare is going insolvent in four years. The challenge is preserving that which is good while squeezing out waste,” said Dr. Cassidy. “This bill is a step in that direction.”


“Federal audits have found that taxpayers have been overpaying bad actors running Medicare Advantage plans by billions of dollars every year, threatening the stability of both Medicare Advantage and traditional Medicare,” said Senator Merkley. “This fraud has to end.”


Traditional Medicare plans reimburse providers for the cost of treatments rendered, while Medicare Advantage is paid a standard rate based on the health of an individual patient. Because of this, Medicare Advantage plans have a financial incentive to make beneficiaries appear sicker than they may be to receive a higher Medicare reimbursement.


The No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act would eliminate those incentives by:

  • Developing a risk-adjustment model that uses two years of diagnostic data instead of just one year.
  • Limiting the ability to use old or unrelated medical conditions to inflate the cost of care.
  • Ensuring Medicare is only charged for treatment related to relevant medical conditions.
  • Closing the gap between how a patient is assessed under traditional Medicare and Medicare Advantage.