Democratic lawmakers are asking GOP leadership to reject Medicaid cuts in favor of going after Medicare Advantage “upcoding” as a way of saving federal dollars and addressing waste, fraud and abuse.
A group of more than 40 bicameral Democratic lawmakers wrote to Senate Majority Leader John Thune (R-S.D.) and Speaker Mike Johnson (R-La.), asking that they reject calls for Medicaid cuts.
“Upcoding” refers to situations in which health care providers submit codes to private insurers, Medicare or Medicaid and make a patient seem sicker than they are, essentially overcharging for an enrollee’s care.
“Where there is widespread agreement is the need to address waste, fraud, and abuse by private, for-profit insurance companies. We write to urge you to crack down on the growing threat to the Medicare program known as ‘upcoding,’” they wrote.
The lawmakers pointed to a Wall Street Journal article published last year that reported Medicare had paid roughly $50 billion to private insurers for diagnosed diseases that physicians never treated.
House Republicans are currently grappling with how to achieve President Trump’s desired cuts in the budget without significantly changing Medicaid benefits. The idea of federal “per capita caps” on benefits has been raised in recent days, but it is opposed by some moderates.
The House Energy and Commerce Committee has been tasked with finding at least $880 billion to cut from the federal budget over the next decade, but doing so will be all but impossible without cutting into Medicaid and the Children’s Health Insurance Program.
If Republicans truly want to achieve savings, Democrats argued they should go after private insurers who offer Medicare Advantage plans, pointing to how an analysis found the Centers for Medicare and Medicaid Services (CMS) “overpaid MA insurers by $83 billion relative to Traditional Medicare in 2024 alone.”
Lawmakers who signed the letters to Thune and Johnson include Democratic Reps. Lloyd Doggett (Texas), Jan Schakowsky (Ill.), Ayanna Pressley (Mass.), Rashida Tlaib (Mich.), Alexandria Ocasio-Cortez (N.Y.) and Maxwell Frost (Fla.).
Those who signed the letter also include Democratic Sens. Elizabeth Warren (Mass.), Ron Wyden (Ore.), Tina Smith (Minn.), Jeff Merkley (Ore.) and Bernie Sanders (I-Vt.).
But Republicans have long supported Medicare Advantage (MA) plans, which are privately run and paid for by the federal government. Roughly half of all Medicare enrollees are expected to be on MA plans in 2025.
Unlike traditional Medicare, under which beneficiaries can go to any hospital or doctor that accepts Medicare, Medicare Advantage enrollees can only go to providers or offices that are in network.
“Moving forward with this dangerous plan to rip health care away from low- and middle-income Americans would be a man-made disaster for the health of the nation and the economy,” the lawmakers wrote, noting that CMS Administrator Mehmet Oz had previously spoken in favor of addressing waste, fraud and abuse in Medicare Advantage plans.
“We urge you instead to listen to Administrator Oz and tackle real fraud, waste, and abuse by private, for-profit health insurers in MA.”
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