Is Your Medicare Advantage Plan Gaming the System? What Upcoding Means for You
Representative Lloyd Doggett’s recent post about Medicare Advantage billing practices gained real traction online — hundreds of shares, thousands of views, and a lot of comments from people asking the same question: “Is my Medicare Advantage plan overcharging the government?”
It’s a fair question. And the answer matters — not just for taxpayers, but for anyone relying on a Medicare Advantage plan for their healthcare.
Let’s break down what’s actually happening, why it matters, and what you can do about it.
What Is Upcoding, and Why Should You Care?
In Medicare Advantage, insurers receive a monthly payment from the government for each enrollee. That payment is supposed to reflect how sick (or healthy) that person is — sicker patients cost more to treat, so plans get paid more.
“Upcoding” happens when a plan adds diagnoses to a patient’s record that aren’t backed up by actual doctor visits or clinical evidence. The plan gets paid more than it should for that patient. Multiply that across thousands — or millions — of enrollees, and the numbers get big fast.
The Office of Inspector General has flagged this issue repeatedly. Audits have found billions in payments tied to diagnoses that weren’t supported by the patient’s medical record. These aren’t small errors. They represent a pattern of billing practices that cost taxpayers real money.
The Taxpayer Impact
When Medicare Advantage plans overbill, it’s not just a line item on a government spreadsheet. Those overpayments come from the same pool of federal dollars that funds Medicare for everyone. That means:
- Higher premiums over time. When the government pays more than it should, the cost doesn’t disappear — it gets spread across the program.
- More pressure on the Medicare trust fund. Medicare’s long-term solvency is already a concern. Billions in improper payments accelerate the problem.
- Less money for actual care. Every dollar lost to upcoding is a dollar that could have gone toward patient services, provider reimbursements, or program improvements.
If you pay taxes — and most of us do — you’re footing part of this bill.
What This Means for Medicare Advantage Enrollees
Here’s where it gets personal. If you’re on a Medicare Advantage plan, upcoding doesn’t just affect your tax bill. It affects the plan you’re counting on.
Your plan’s “risk score” may be inflated. Risk scores determine how much your plan gets paid. If the score is artificially high, your plan is collecting more than it should. That extra money isn’t necessarily going toward better care for you.
Your out-of-pocket costs could be higher than necessary. Plans that collect inflated payments aren’t necessarily passing savings to enrollees. In some cases, higher reimbursement lets plans offer flashy extras (dental, vision, gym memberships) while the core medical coverage — the stuff you actually need when you’re sick — stays thin.
The care you receive may not match what you’re being billed for. If your plan is adding diagnoses to your record, those diagnoses should be reflected in your actual care plan. If they’re not, something’s off.
What If You Have Original Medicare?
If you’re on Original Medicare (Parts A and B), the upcoding issue doesn’t affect you directly. Original Medicare pays providers based on actual services rendered, not on diagnoses added to a patient record.
But the ripple effects are real. Higher program costs from Medicare Advantage overpayments put pressure on the entire Medicare system — including Original Medicare’s funding and future.
What You Can Do
The best defense against billing practices that don’t serve you is understanding your coverage and making sure it fits your needs. Here’s where to start:
Review your Medicare Advantage plan annually. During the Annual Enrollment Period (October 15 – December 7), take a close look at what your plan covers, what it costs, and whether it still fits your health needs and budget.
Ask questions about your diagnoses. If you receive an Explanation of Benefits (EOB) that lists a condition you don’t recognize, call your plan and ask about it. You have a right to understand what’s on your record.
Consider whether Medicare Supplement might be a better fit. Medicare Supplement (Medigap) plans work with Original Medicare and don’t rely on the same risk-score billing model. They offer predictable out-of-pocket costs and the freedom to see any doctor that accepts Medicare. For some people, that predictability is worth more than the extras a Medicare Advantage plan might offer.
Talk to an independent agent who works for you. An independent insurance agent can review your current plan, compare it to other options in your area, and help you find coverage that actually matches your health needs — without the fine print surprises.
How Trek Insurance Solutions Can Help
At Trek Insurance Solutions, we believe you deserve to know exactly what you’re paying for — and what you’re getting. We review Medicare plans across multiple states with access to 7 organizations offering 42 products in our active service areas.
We’ll look at your current coverage, compare it to what’s available, and give you an honest assessment. If your plan is serving you well, we’ll tell you. If there’s a better option that fits your health needs and your budget, we’ll walk you through it — no pressure, no confusion, just clear guidance.
Your Medicare coverage should work for you, not against you.
Contact us at 888-960-0442 or visit trekis.net to review your options.
Trek Insurance Solutions is a Third-Party Marketing Organization (TPMO). We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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