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Medicare Advantage insurers face new curbs on overcharges in Trump plan
Dr. Mehmet Oz leads the Centers for Medicare & Medicaid Services. A CMS plan to keep payments to Medicare Advantage flat in 2027 roiled health insurance stocks this week.
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Medicare Advantage health plans are blasting a government proposal this week that would keep their reimbursement rates flat next year while making other payment changes.
But some health policy experts say the plan could help reduce billions of dollars in overcharges that have been common in the program for more than a decade.
On Jan. 26, Centers for Medicare & Medicaid Services officials announced they planned to raise rates paid to health plans by less than a tenth of a percent for 2027, far less than the industry expected. Some of the largest, publicly traded insurers, such as UnitedHealth Group and Humana, saw their stock prices plummet as a result, while industry groups threatened that people 65 and older could see service cuts if the government didn’t kick in more money.
In Medicare Advantage, the federal government pays private insurance companies to manage health care for people who are 65 and older or disabled.
“Chart reviews”
Less noticed in the brouhaha over rates: CMS also proposed restricting plans from conducting what are called “chart reviews” of their customers. These reviews can result in new medical diagnoses, sometimes including conditions patients haven’t even asked their doctors to treat, that increase government payments to Medicare Advantage plans.
The practice has been criticized for more than a decade by government auditors who say it has triggered billions of dollars in overpayments to the health plans. Earlier this month, the Justice Department announced a record $556 million settlement with the nonprofit health system Kaiser Permanente over allegations the company added about half a million diagnoses to its Advantage patients’ charts from 2009 to 2018, generating about $1 billion in improper payments.
KP did not admit any wrongdoing as part of the settlement.
“I do think the administration is serious about cracking down on overpayments,” said Spencer Perlman, a health care policy analyst in Bethesda, Maryland.
Perlman said that while the Trump administration strongly supports Medicare Advantage, officials are “troubled” by plans that rake in undue profits by using chart reviews to bill the government for medical conditions even when no treatment was provided.
In a news release, CMS Administrator Mehmet Oz said curbing this practice would ensure more accurate payments to the plans while “protecting taxpayers from unnecessary spending that is not oriented towards addressing real health needs.”
“These proposed payment policies are about making sure Medicare Advantage works better for the people it serves,” Oz said.
Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, called the proposal “at least a mildly encouraging sign,” though he said he suspected health plans might eventually find a way around it.
Kronick has argued that switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in the government-run Medicare program, because of unbridled medical coding excesses. The insurance plans have grown dramatically in recent years and now enroll about 34 million members, or more than half of people eligible for Medicare.
David Meyers, an associate professor at the Brown University School of Public Health, called the proposed restriction on chart reviews “a step in the right direction.”
“I think the administration has been signaling pretty strongly they want to cut back on inefficiencies,” he said.
The outcry from industry, mostly directed at the proposal to essentially hold Medicare Advantage payment rates flat, was quick and sharp.
“If finalized, this proposal could result in benefit cuts and higher costs for 35 million seniors and people with disabilities when they renew their Medicare Advantage coverage in October 2026,” said Chris Bond, a spokesperson for AHIP, formerly known as America’s Health Insurance Plans.
CMS is accepting public comments on the proposal and says it will issue a final decision on the payment rates and other provisions by early April.
Meyers said health plans often claim they will be forced to slash benefits when they aren’t satisfied with CMS payments. But that rarely happens, he said.
“The plans can still make money,” he said. “They mostly are very profitable, just not as profitable as shareholders expected.”
The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and other investigations have alleged that health plans exaggerate how sick their customers are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”
Many Medicare Advantage health plans have hired medical coding and analytics consultants to review patients’ medical charts to find new diagnoses that they then bill to the government. Medicare rules require that health plans document — and treat — all medical conditions they bill.
Yet federal audits have shown for years that many health plans’ billing practices don’t hold up to scrutiny.
A December 2019 report by the Department of Health and Human Services inspector general found that the health plans “almost always” used chart reviews to add, rather than delete, diagnoses. “Over 99 percent of chart reviews in our review added diagnoses,” investigators said.
The report found that diagnoses reported only on chart reviews — and not on any service records — resulted in an estimated $6.7 billion in payments for 2017.
This week’s proposal is not the first time CMS has tried to crack down on chart reviews.
In January 2014, federal officials drafted a plan to restrict the practice, only to abruptly back off a few months later amid what one agency official described as an “uproar” from the industry.
The health insurance industry has for years relied on aggressive lobbying and public relations campaigns to fight efforts to rein in overpayments or otherwise reduce taxpayers’ costs for Medicare Advantage.
What happens this time will say a lot about the seriousness of the Trump administration in its crack down on controversial, long-standing payment practices in the program.
Perlman, the policy analyst, said it is “quite common” for CMS to partially backtrack when faced with opposition from the industry, such as by phasing in changes over several years to soften the blow on health plans.
David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm, said finalizing the chart review proposal “would be a meaningful step towards reining in overpayments to Medicare Advantage plans.
“But in the past, he said, even a minor change to Advantage payments has led the industry to protest that “the sky will fall as a result, and the proposal is usually dropped.”
“It’s hard to tell at this stage how this will play out,” Lipschutz said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF.
Lionel Messi #10 of Argentina celebrates scoring his team’s second goal during their World Cup match against Egypt in Atlanta on Tuesday.
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They looked beaten. And out. Argentina, the defending World Cup champion and No. 1-ranked team, was down 2-0 late against Egypt.
Then, in a span of 13 remarkable minutes, Argentina scored not once, not twice, but three times, capping a comeback for the ages and leaving Egypt stunned and shellshocked.
For much of the game in Atlanta, Egypt was in control, hobbling Argentina early. The Egyptian attack began almost immediately with a stunning header goal delivered by Yasser Ibrahim in the 15th minute. After that, Egypt’s defense closed ranks, making it practically impossible for Argentina to equalize.
It was downhill from there for the Argentines: team captain Lionel Messi failed to convert a penalty kick, and in the 67th minute, Egypt got a second goal from Mostafa Ziko (after an earlier Egyptian goal had been disallowed after a video review). It looked like Argentina was finished. On the brink of elimination.
But no one told the Argentine players that.
In the 79th minute, Lionel Messi began doing his thing. He fired a cross near the Egyptian goal, and Cristian Romero headed it in. Messi was not done. Four minutes later, he powered a shot past the Egyptian keeper. It was his eighth goal of this tournament, the most of any player. The score was 2-2.
Then, in stoppage time, yet another Argentina header and another goal, this time from Enzo Fernandez.
“This is the World Cup for you,” said Messi after the game. “It wasn’t easy to come back from two goals down. But as I always say, this group never gives up. We always try to fight until the end.”
French referee François Letexier speaks with Egypt forward Mohamed Salah during the World Cup Round of 16 match between Argentina and Egypt in Atlanta.
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Afterward, Egypt coach Hossam Hassan complained about the French referee and the officiating. “I am not convinced. I am not convinced with this outcome. I’m not convinced with the way things unfolded during this match,” said Hassan in a post-match news conference. “We have been treated unfairly today. We have suffered injustice.”
“We would have deserved to earn this win, but we are leaving with honor, with pride, regardless of this defeat,” said Hossan.
African soccer teams have been the stars of this World Cup. Morocco has yet to lose a game. Cape Verde qualified for the first time in its history and stymied Spain, Uruguay and Saudi Arabia. Argentina barely beat them in a nail-biter of a match.
For Egypt, getting this far in the tournament is historic in itself: it’s the first time the team has made it this far. For Argentina, it was a terrifying yet relieving victory: several players, including Messi himself, cried after the game.
Next, they move to the quarterfinals and will play the winner of today’s Switzerland-Colombia match.
Top Senate Democrats are pushing for answers on whether a provision in a controversial settlement agreement between President Trump and his own administration applies to companies co-founded by or affiliated with the Trump family.
As part of a deal struck in May by the Justice Department to resolve a lawsuit brought by Mr. Trump, the Internal Revenue Service is permanently barred from pursuing claims against Mr. Trump, his oldest sons Don Jr. and Eric, and the Trump Organization based on prior tax returns.
In a one-page document signed by Acting Attorney General Todd Blanche and dated May 19, the Justice Department said the defendants in the president’s lawsuit — the IRS and the Treasury Department — are “FOREVER BARRED and PRECLUDED” from “prosecuting or pursuing, any and all claims” arising from tax returns filed before the settlement took effect. Blanche also wrote that the settlement applies to “parties including trusts, parent, sister, or related companies, affiliates, and subsidiaries.”
Now, Senators Elizabeth Warren of Massachusetts, Senate Minority Leader Chuck Schumer of New York, and Ranking Member of the Senate Finance Committee Ron Wyden of Oregon are pushing 11 businesses and organizations with ties to the Trump family to get answers for the “significant questions” the settlement raises relating to the tax audit provision, and whether the companies are included in the deal.
“Under the guise of a so-called legal settlement, the Trump administration has attempted to decree that the President, his family, and their entire business empire — potentially including entities with even the vaguest ‘affiliation’ to the family — are to face zero consequences if they have committed a range of financial crimes or misdeeds — regardless of the severity of the violation,” the senators wrote in letters transmitted to the companies Monday night.
The letters were sent to mining company Kaz Resources, defense firm Powerus, cryptocurrency companies World Liberty Financial and American Bitcoin, robotics startup Foundation Future Industries, investment firm 1789 Capital, private aviation company Tag Air, and prediction markets Polymarket and Kalshi.
All of the companies either were founded by Mr. Trump and his two adult sons, or list members of the Trump family as advisers, board members, or partial owners. Donald Trump Jr. sits on Polymarket’s advisory board and 1789 Capital, where he’s a partner, has invested in Polymarket. Days before Mr. Trump took office for his second term, Kalshi also announced Trump Jr. would be a strategic adviser.
The Democrats, who are in the minority, lack subpoena power, so Mr. Trump, his children and his companies can’t be forced to answer the questions posed by the senators.
According to recent financial disclosures, the president earned more than a billion dollars from cryptocurrency ventures alone last year, including from his meme coin business and World Liberty Financial, his family’s cryptocurrency firm.
Separately, the senators also asked the Trump Organization in a separate letter if it believes it has “immunity from all audits, civil penalties or federal prosecution” for any crimes that could have occurred before the settlement.
Trump Media and Technology Group, which is majority owned by a trust that lists Mr. Trump as the sole beneficiary and operates the Truth Social platform he uses daily, also received a letter from the Democratic senators.
“The public deserves transparency about the scope of this get-out-of-jail free card for Trump-aligned businesses, and about whether you intend to rely on this settlement as a free pass for any possible violations of the law,” the senators continued in their letter, which also seeks any communications that executives at the companies have had with the Justice Department and White House leading up to or after the settlement was signed.
The settlement was announced months after Mr. Trump and two of his sons and the Trump Organization accused the IRS and Treasury Department of unlawfully allowing a government contractor to leak tax returns to media outlets in 2020.
In a statement, a Justice Department spokesperson said “the IRS routinely provides releases as part of resolving taxpayer reviews and audits. This settlement follows that same standard practice.”
The spokesperson did not provide specific information about which companies are covered by the audit provision, or whether the Trump Organization and Trump family are the only entities covered by that addendum.
Charles De Ketelaere #17 of Belgium celebrates after scoring his team’s second goal during the World Cup Round of 16 match against the United States on Monday in Seattle.
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SEATTLE — This time was supposed to be different.
The U.S. men’s national team came into this FIFA World Cup with a lineup full of players with key roles in Europe’s top leagues. They had the name-brand coach — Mauricio Pochettino, of Tottenham, PSG and Chelsea fame. And they had homefield advantage, with every game on U.S. soil for the first time in three decades.
For weeks, the hype seemed like it might be real: The team’s three wins over Paraguay, Australia and Bosnia-Herzegovina were the most ever by a U.S. men’s squad in a World Cup. A new generation of American fans filled stadiums by the tens of thousands and tuned in on TV by the tens of millions.
But in the end, the Americans’ exit was the same as it ever was: Eliminated yet again in the Round of 16 at the hands of a European team — this time, Belgium, by a score of 4-1.
From the moment they stepped onto the Seattle field, the U.S. was outclassed by their opponent, No. 9-ranked Belgium. Countless turnovers and defensive lapses were seized on by the Belgians, who needed only nine minutes to take a 1-0 lead.
Then, once the Americans equalized on a free kick by midfielder Malik Tillman, Belgium scored yet again in barely a minute of play. Belgian forward Charles De Ketelaere scored both his team’s first-half goals.
After halftime, came an embarrassing nail in the coffin that silenced the Seattle sellout crowd for good — a 57th minute roll-in by Hans Vanaken after a slip-up by goalkeeper Matt Freese outside of the penalty area left the goal unguarded. Belgian forward Romelu Lukaku added a stoppage-time goal to seal the final score at 4-1.
Malik Tillman #17 of the United States celebrates scoring his team’s only goal during their World Cup match against Belgium. In what was one of the few bright spots of the game, the U.S. pulled even with Belgium at 1-1. The tie lasted less than two minutes before Belgium scored again.
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“It stinks,” said U.S. midfielder Tyler Adams. “Tonight was not a good performance overall. It’s not what we look to achieve. There [were] a lot of things that we could have done better.”
The U.S. had entered Monday’s game under a cloud of controversy around their striker Folarin Balogun, who was shown a red card in last week’s Round of 32 match against Bosnia-Herzegovina. An automatic one-game suspension was set to sideline Balogun, the Americans’ leading scorer at the World Cup, for Monday’s game.
Then, the day before the game, a FIFA disciplinary panel took the highly unusual step of delaying Balogun’s suspension by a year to allow him to participate. Then, news broke that President Trump had personally called FIFA president Gianni Infantino to encourage him to review the red card.
The Royal Belgian Football Association said it would protest Balogun’s inclusion in the lineup. But even at full strength, the U.S. were never real contenders in Monday’s game.
U.S. defender and team captain Tim Ream said the controversy swirling around the team had no impact. “We were fully focused on us as a group and as a team and fully focused on the game and not really worrying about what was being said or debated in the outside world.”
Belgium will advance to the quarterfinals for the third time in the past four World Cups, where it will face Spain on Friday in Los Angeles.
Mauricio Pochettino, Head Coach of the United States, walks down the touchline during the Round of 16 World Cup match between the USA and Belgium in Seattle on Monday.
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