A new bipartisan bill—the No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act—is turning up the heat on Medicare Advantage coding practices. Introduced by Senators Bill Cassidy (R-LA) and Jeff Merkley (D-OR), the legislation aims to curb overpayments driven by inflated risk scores and coding practices that don’t hold up under scrutiny.
For health plans and provider groups, this is more than just proposed legislation—it’s a signal that the compliance bar is rising fast. Are your coding processes ready?
Why is Medicare Advantage Coding Under Fire?
Medicare Advantage (MA) plans are reimbursed based on the documented health risk of their members. The higher the risk score, the greater the payment. While this model is intended to ensure appropriate funding for high-need patients, it has also created opportunities—intentional or not—to overstate patient risk through coding.
Senators Cassidy and Merkley argue that this system has cost taxpayers billions in unnecessary payments. According to the Congressional Budget Office, addressing over-coding could save $124 billion over 10 years.
“The Medicare trust fund is running out. We need to stop overpaying where we can if we’re to preserve Medicare for Americans who rely on it,” said Dr. Cassidy. Senator Merkley echoed this urgency: “Fraud, waste, and abuse...must end.”
What would change under the No UPCODE Act?
The bill seeks to eliminate coding practices that inflate risk scores without clear, relevant medical justification. Key provisions include:
- Using two years of diagnostic data to calculate risk scores, rather than just one. This would provide a fuller picture of patients' health.
- Limiting use of unrelated or outdated diagnoses when determining payments.
- Aligning assessments between traditional Medicare and Medicare Advantage to ensure consistency and fairness.
- Charging Medicare only for care tied to relevant, documented conditions.
These changes would close loopholes that allow for inflated payments and reinforce the need for accurate, defensible coding.
What This Means for Providers and Plans
If your coding can’t stand up to audit scrutiny today, you’re at risk. The No UPCODE Act is part of a larger movement: CMS audits are getting smarter, RADV findings can now be extrapolated across populations, and penalties are rising. Compliance isn’t just about getting paid—it’s about protecting your organization from significant financial and reputational harm.
👉 Want to protect your organization?
Download Aptarro’s Risk Adjustment Playbook for guidance on building compliant, defendable coding strategies that withstand audit scrutiny and regulatory change.
