Congress moves to stop Medicare Advantage plans from gaming diagnosis codes

What it does

This bill amends Medicare Advantage risk adjustment rules to reduce overpayments caused by aggressive diagnosis coding. Starting in 2026, it requires the government to use two years of diagnostic data instead of one, excludes diagnoses found only through chart reviews and health risk assessments (common sources of upcoding), and mandates annual evaluation of coding differences between Medicare Advantage plans and traditional Medicare providers, with public reporting and potential plan-level adjustments to correct for inflated risk scores.

Why we flagged it

The bill's core mechanism is to reduce systematic overpayment of Medicare Advantage plans through stricter diagnosis data sourcing and mandatory coding-pattern audits. It is fundamentally an anti-fraud and fiscal-accountability measure, not a subsidy or deregulation.

What the text implies

• Medicare Advantage insurers may respond by reducing supplemental benefits (dental, vision, hearing) or narrowing provider networks to offset lower risk-adjustment payments, potentially harming beneficiary access even as government payments decline.
• The exclusion of chart-review diagnoses may inadvertently penalize legitimate clinical documentation practices if the Secretary's identification procedures cannot reliably distinguish between appropriate chart reviews and upcoding schemes.
• Publicly reporting coding-pattern differences may create competitive pressure on traditional Medicare providers and accountable care organizations to adopt more aggressive coding to match MA plans, spreading the problem rather than solving it.
• The bill does not address the underlying incentive structure that rewards MA plans for higher risk scores; coding tightening alone may not eliminate the financial motive for diagnosis inflation if payment formulas remain risk-adjusted.

Section numbers refer to the bill text the analysis read — linked under Primary records below.

Who it affects

Medicare Advantage plans have systematically inflated diagnosis coding to increase government payments, raising premiums and out-of-pocket costs for beneficiaries and wasting taxpayer money. This bill directly addresses that abuse by tightening the data sources used to calculate payments and requiring transparency about coding disparities, protecting both seniors and the Medicare trust fund.

Who stands to gain

• Medicare trust fund (reduced overpayments)
• Medicare beneficiaries (lower premiums and out-of-pocket costs)
• Taxpayers (reduced federal spending on Medicare Advantage)

Named in the bill

Centers for Medicare & Medicaid Services (CMS), Medicare Advantage plans, Medicare Parts A and B providers, Social Security Administration, Bristol Myers Squibb (BMY), Guardant Health (GH), Pfizer (PFE), DaVita (DVA), Johnson & Johnson (JNJ)

Where it stands

1 cosponsor: 1 Democrats.

• Mar 25, 2025 — Introduced · Congress.gov: “Introduced in Senate”
• Mar 25, 2025 — Referred to Senate Committee on Finance · Congress.gov: “Read twice and referred to the Committee on Finance”

Dates and quoted wording are Congress.gov's action record; the timeline shows status changes, not every procedural step.

Money around this bill

41 lobbying clients named this bill on 60 disclosure filings across 2 quarters, Dec 2025 to Jun 2026. Those filings disclosed $20,993,128 in lobbying spend. A filing names 8 bills on average, so that figure is what each filing reported, not a share belonging to this bill.

More lobbying clients named this bill than 99% of bills with at least one filing.

Bill Cassidy, the sponsor, reported $1,329,254 in PAC receipts in the 2026 cycle. $3,600 of that came from 2 PACs tied to these lobbying clients.

• AARP — $5,300,000 on 1 filing
• CVS Health (and Subsidiaries) — $3,570,000 on 1 filing
• Kaiser Foundation Health Plan Inc — $1,950,000 on 3 filings
• Blue Cross and Blue Shield Association — $1,440,000 on 1 filing
• Cambia Health Solutions — $1,330,000 on 2 filings

Lobbying Disclosure Act filings through Jul 20, 2026. A filing shows who paid to lobby on a bill it names, not what changed.