The Honorable Xavier Becerra
Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Dear Secretary Becerra:

On behalf of the undersigned organizations, representing people with Medicare, families, and providers, we applaud the administration for taking important steps in the final CY2025 Medicare Advantage (MA) Rate Announcement to hold MA plans and organizations accountable to delivering the high quality, affordable, and equitable care that people who rely on Medicare need and deserve.

Too often, MA organizations and plans engage in harmful business practices and corporate abuses that negatively impact people with Medicare and other taxpayers. These practices include aggressive care denials and prior authorization restrictions that do not correspond with what is required to be covered under Traditional Medicare; predatory and deceptive marketing schemes to prospective enrollees; and systematic upcoding of patient diagnoses that do not reflect the actual care that enrollees are receiving, among other abuses. Taken together, these practices are driving hundreds of billions of dollars in overpayments and raises serious concerns about accountability for MA plans to deliver high-quality, high-value, and equitable care.

We applaud what the administration has done to begin to rein in harmful MA plan practices to date, including in this final Rate Announcement, and we stand ready to support you as you move to implement these improvements. We also feel strongly that continued abuses in the MA program warrant that the administration go even further towards addressing unscrupulous business practices of MA plans, and we want to serve as key partners in informing future efforts. By comprehensively addressing these abuses, we can ensure that tens of millions of older adults will have greater access to high-quality and affordable health care.

As you know, systematic upcoding is when an MA plan or organization reduces the accuracy of MA payments by making their MA enrollee population appear sicker and costlier than they really are. This occurs despite the fact that MA enrollees actually tend to be healthier than patients in Traditional Medicare. MA plans have gone so far as to upcode and assign erroneous patient diagnoses – through sham chart reviews and health risk assessments (HRAs) – that are not medically supported (i.e., not supported by the patient’s medical record) or do not result in any additional medically necessary treatment or care.

Ultimately, these upcoding abuses lead to billions of dollars of overpayments, wasting taxpayer dollars and putting Medicare’s long term financial position at risk. They also hurt the health and financial well-being of all those who rely on Medicare by driving up enrollee out-of-pocket costs and Part B premiums and, importantly, undermining the extent to which the MA payment system can hold plans accountable to delivering high quality and equitable care. Compounding these concerns that MA plans are not truly held accountable to delivering high quality and equitable care is a lack of meaningful transparency and oversight of MA plans, an ineffective MA quality program, and growing evidence of adverse selection.

In the final CY2025 Rate Announcement, the Centers for Medicare & Medicaid Services (CMS) finalized its proposal to continue implementing an updated risk adjustment model (i.e., the 2024 CMS-HCC Risk Adjustment Model) that will help promote more accurate payments to MA organizations and plans, ensuring those payments truly reflect and account for the expected costs of each enrolled patient. This is an important step toward limiting MA plans’ ability to upcode and bill for sham diagnoses that are often never even treated.

Yet we believe more needs to be done to rein in the harmful practices of MA plans, particularly around systematic upcoding and overpayments. For instance, we are disappointed CMS chose to only apply a coding pattern adjustment at the statutory minimum, despite having clear authority to go further. Combined with the relatively modest improvements to the risk adjustment model, these coding adjustments do not fully address nor rein in the differences in MA coding intensity and upcoding relative to Traditional Medicare, nor does it mitigate the resulting harms to those who rely on Medicare and taxpayers.

Therefore, we recommend CMS enact the following changes in future rulemaking:

· Apply a higher coding adjustment factor above and beyond what is minimally required in statute to fully account for intensive coding by MA plans. We recommend using a tiered approach that targets MA plans who engage in upcoding to the greatest extent in order to remove their unfair advantage as compared to other MA plans.

· Exclude information exclusively collected via in-home health risk assessments (HRAs) or chart reviews as a source of diagnoses for MA risk adjustment scores and payments, as they are easily abused and represent a significant driver of coding intensity and upcoding as noted by MedPAC and HHS OIG.

· Use two years of traditional Medicare and MA diagnostic data for calculating MA risk-adjusted payments to avoid allowing erroneous diagnoses, such as those due to errors or inappropriate coding from one particular year, to drive upcoding and overpayments in MA.

We applaud CMS and the administration for taking meaningful steps towards reining in harmful business practices and corporate abuses in the MA program in this final rate announcement. As the MA Program continues to experience record enrollment and now provides health care coverage to over half of all Medicare beneficiaries, we look forward to continuing to partner with the administration, and specifically with HHS and CMS, on how to further ensure that those that rely on MA receive the high-quality, affordable, and equitable care they deserve.

Sincerely,

Families USA
Center for Medicare Advocacy
Justice in Aging Medicare Rights Center

 

AgeOptions
AIDS Action Baltimore Allergy & Asthma Network
Alliance For Retired Americans
American Academy of Pediatrics- Nebraska Chapter Asian Resources, Inc.
Autistic Women & Nonbinary Network Be A Hero
Breast Cancer Action
Bruno-Smithfield Community Health Centers Center for Elder Law and Justice
Center For Health and Democracy Christian Council of Delmarva Colorado Consumer Health Initiative Central Virginia Health Services Democratic Disability Caucus of Florida
Global Alliance for Behavioral Health and Social Justice Grainpro Inc.
Health Action New Mexico
Hennepin Healthcare – HCMC Iowa Citizen Action Network Konocti Senior Support, Inc.
Labor Campaign for Single Payer
Lighthouse Community Development Corporation Long Term Care Community Coalition
Lupus and Allied Diseases Association, Inc. Maternal and Child Health Access
National Adult Day Services Association (NADSA) National Association of Social Workers (NASW)
National Committee to Preserve Social Security and Medicare
New Jersey Association of Mental Health and Addiction Agencies, Inc. New Jersey Citizen Action
One Health Resource Project H.E.L.P USA
South Carolina Appleseed Legal Justice Center Transgender Awareness Alliance
Tennessee Healthcare Campaign
Texas Central Hemophilia Association
The Office of the Health Care Advocate – Vermont Legal Aid Triage Cancer
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