Warren, Doggett Urge Medicare Administrator to Crack Down on Abuse by Private Insurers In Medicare Advantage

Warren, Doggett Urge Medicare Administrator to Crack Down on Abuse by Private Insurers In Medicare Advantage

"It is your duty to protect taxpayer dollars from waste and abuse and the preservation of these funds will protect the promise of Medicare for future generations by stabilizing the Medicare Trust Fund"

Letter comes as Dr. Mehmet Oz, nominee to head Medicare and Medicaid, promotes further expansion of Medicare Advantage and elimination of Traditional Medicare

Text of Letter (PDF)

Washington, D.C. - U.S. Senator Elizabeth Warren (D-Mass.) and Representative Lloyd Doggett (D-Texas) urged the Center for Medicare and Medicaid Services (CMS) to finalize rules to curb overpayments to private insurers in Medicare Advantage (MA).

The nonpartisan Medicare Payment Advisory Commission (MedPAC) estimates that private insurers in MA will overcharge taxpayers $83 billion this year alone. Most of these overpayments are the result of "upcoding," a tactic in which private insurers deliberately add incorrect diagnosis codes to patients' medical charts to secure higher payments from the federal government. In total, MedPAC estimates that upcoding by private insurers in MA will cost taxpayers $54 billion in 2024 alone.

In March 2023, CMS proposed changes to the program's payment methodology, including eliminating overpayments associated with codes that were subject to widespread manipulation"by private insurers in MA. However, a multi-million dollar lobbying campaign by the health insurance industry led CMS to phase these changes in over three years instead of upfront.

The letter urges Administrator Brooks-LaSure to propose the 2026 MA payment rule quickly, and to include the third-year of CMS' proposed changes and more aggressive action to curb overpayments to private insurers in MA. These changes are critical following Dr. Mehmet Oz's nomination to lead CMS, given his support for making Medicare Advantage the default option for seniors and eliminating Traditional Medicare. Dr. Oz also has millions invested in companies with interests before CMS, a clear conflict of interest.

"Without your swift action, the situation will only worsen as President-elect Trump and Congressional Republicans prepare multi-trillion-dollar legislation to provide even greater tax cuts to multinational corporations and the very wealthiest few at the expense of social safety net programs, including Medicare," wrote the lawmakers.

Although MA insurers and their promoters often mislabel these crackdowns as "cuts to Medicare," payments to MA continue to rise each year. Despite these gross overpayments, private insurers in MA routinely violate Medicare coverage guidelines, squeeze independent physician practices, limit networks, and engage in deceptive marketing to lure seniors to their plans. The lawmakers urged CMS to finalize the phase-in the 2026 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies this month.

Senator Warren is a leading voice on reining in abuses in Medicare Advantage and protecting patients:

• In December 2024, Senators Elizabeth Warren (D-Mass.), Ron Wyden (D-Ore.), Dick Durbin (D-Ill.), Jeff Merkley (D-Ore.), and Representative Lloyd Doggett (D-Texas) wrote to Dr. Mehmet Oz, President-elect Donald Trump's pick to lead the Centers for Medicare & Medicaid Services (CMS), raising stark concerns about his advocacy to eliminate Traditional Medicare and his deep financial ties to the private health insurers that would benefit from that move.
• In May 2024, U.S. Senator Elizabeth Warren (D-Mass.) sent a letter to Chiquita Brooks-LaSure, the Administrator of the Centers for Medicare and Medicaid Services (CMS), responding to the agency's request for information (RFI) on Medicare Advantage (MA) data and raising concerns that CMS does not collect adequate data to determine when vertically integrated insurance companies in MA may be using anti-competitive tactics to raise health care costs and pocket extra profits.
• In May 2024, at a hearing of the U.S. Senate Committee on Finance, Senator Warren called out private insurers in Medicare Advantage for accelerating the rural hospital crisis.
• In March 2024, Senators Warren and Brown led their colleagues in a letter to HHS and CMS that urged the agencies to protect seniors by holding insurance companies accountable for abuses in Medicare Advantage.
• In January 2024, Senator Warren and Representative Pramila Jayapal (D-Wash.) sent a letter to CMS, urging the agency to take administrative action to curb billions in overpayments to MA insurers.
• In December 2023, Senators Warren, Catherine Cortez Masto (D-Nev.), Bill Cassidy (R-La.), and Marsha Blackburn (R-Tenn.) sent a letter to the CMS Administrator Chiquita Brooks-LaSure, raising concerns about shortfalls in CMS's data collection and reporting practices for MA plans, and urging CMS to close data gaps to strengthen oversight of MA plans and improve care for Medicare beneficiaries.
• In November 2023, Senators Warren, Cortez Masto, Cassidy, and Blackburn introduced bipartisan legislation to improve transparency of MA plans and ensure these plans are best serving the health care needs of America's seniors. The Encounter Data Enhancement Act would require Medicare Advantage plans to report important information about how much they are actually paying for patient services and how much patients are responsible for paying out-of-pocket.
• In November 2023, Senators Warren and Braun urged the Department of Health and Human Services (HHS) Inspector General to determine if vertically-integrated health care companies are hiking prescription drug costs, evading federal regulations.
• In November 2023, at a Senate Finance Committee markup of the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act, Senator Warren highlighted the need to do more to prioritize hearing health for seniors and strengthen transparency in Medicare Advantage, and secured commitments from Senate Finance Committee leadership to prioritize these proposals in future packages.
• In October 2023, at a hearing of the Senate Finance Committee, Senator Warren called out giant MA insurers for using deceptive marketing tactics to lure seniors into the wrong plans and drown out competition from smaller insurers that may offer better coverage. Senator Warren called on CMS to act within the fullest extent of its authority to crack down on MA insurers that game the system to overcharge the government and to ensure insurers publish accurate data on patient care and out-of-pocket costs.
• In May 2023, at a hearing of the Senate Finance Committee, Senator Warren highlighted the prevalence of ghost networks in Medicare Advantage plans and called for stronger oversight of the program.
• In March 2023, Senator Warren sounded the alarm on a new analysis by policy experts showing that all Medicare beneficiaries - including those enrolled in Traditional Medicare - are paying higher premiums due to overpayments in MA. She sent a letter to CMS and called on the agency to finalize its proposed rule to ensure payments to MA plans accurately reflect the cost of care.
• In March 2023, U.S. Senators Warren and Jeff Merkley (D-Ore.) sent letters to the top seven MA insurers - Humana, Centene, UnitedHealthcare, CVS/Aetna, Molina, Elevance Health, and Cigna - regarding their questionable claims that CMS's 2024 proposed Medicare Advantage payment rules would hurt beneficiaries.
• In March 2023, at a hearing of the Senate Finance Committee, Senator Warren defended CMS's proposed adjustments to the Calendar Year 2024 MA payment rates, pushing back against giant insurance companies and their lobbyists who are peddling misinformation to protect their billions in profits and scare beneficiaries into opposing the rule.
• In April 2022, Senator Warren and Representatives Katie Porter (D-Calif.), Rosa DeLauro (D-Conn.), and Jan Schakowsky (D-Ill.) led their colleagues in sending a letter to CMS Administrator Chiquita Brooks-LaSure highlighting concerns about overpayments to Medicare Advantage plans that line the pockets of big insurance companies.
• In February 2022, chairing a hearing of the Senate Finance Subcommittee on Fiscal Responsibility and Economic Growth, Senator Warren delivered remarks about strengthening Medicare and cracking down on pharmaceutical and insurance companies' corporate greed to pay for expanded coverage.

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