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Medicare Advantage insurers face new curbs on overcharges in Trump plan

Published

2 months ago

January 29, 2026

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.

Anna Moneymaker/Getty Images

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Anna Moneymaker/Getty Images

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.

Older Americans say they feel trapped in Medicare Advantage plans

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.

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Video: The Fragile Cease-Fire in Iran

Published

5 hours ago

April 9, 2026

Press Room

President Trump announced a conditional cease-fire with Israel on Iran, but the fundamental issues that led to the war remain unresolved.

By David E. Sanger, Alexandra Ostasiewicz, Stephanie Swart, Ray Whitehouse, Paul Abowd and Jon Miller

April 8, 2026

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Jim Whittaker, the first American to summit Mount Everest, dies at 97

Published

8 hours ago

April 9, 2026

Press Room

Jim Whittaker, the first American to summit Mount Everest, dies at 97

Jim Whittaker is interviewed for the 50th Anniversary Celebration of the First American Ascent of Mount Everest in Berkeley, Calif., Feb. 22, 2013.

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SEATTLE — The celebrated mountaineer Jim Whittaker, the first American to summit Mount Everest, has died. He was 97.

Whittaker, who also served as the first full-time employee of the outdoor retailer REI and later as its president and CEO, died Tuesday at his home in Port Townsend, Washington, according to a statement from his family.

“Whether at home, in the mountains, or at sea, he sought to share adventure, joy, and optimism with those around him,” said the statement, which was emailed by Leif Whittaker, one of his sons. “His warmth, humility, and belief in the power of nature to bring people together left an enduring legacy of care for our planet and for one another.”

Whittaker’s 1963 ascent of Everest alongside Nawang Gombu came 10 years after the pioneering climb of Sir Edmund Hillary and Tenzing Norgay. The feat helped spawn interest — and an industry — in mountaineering in the U.S., and it made the once-shy, rangy climber an instant celebrity. He was featured on magazine covers and in demand for public appearances.

Whittaker had been working for REI since 1955, when he was hired by the co-op’s co-founder, Lloyd Anderson. The company’s popularity surged after Whittaker’s Everest climb, and Whittaker went on to lead the business from 1971 to 1979. Its membership grew from nearly 250,000 to more than 900,000 during his tenure, REI noted in a statement Wednesday.

Robert F. Kennedy, left, stands atop Mt. Kennedy after placing a black flag in memorial to his late brother, President John F. Kennedy, next to, from left, Jim Whittaker, William Allard, and George Senner, March 24, 1965, in Yukon, Canada.

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Doug Wilson/AP

The co-op credited his congressional testimony and other efforts with helping to establish North Cascades National Park and the Pasayten Wilderness in Washington, as well as and Redwood National Park in California.

“Long before outdoor advocacy was commonplace, Jim gave his voice — and his leadership — to protecting the places we love, reminding us that wild places endure only if we choose to care for them,” the statement said.

Whittaker’s celebrity also brought him into the orbit of the Kennedy clan, and he became a close friend of Robert Kennedy, with whom he climbed a 14,000-foot (4,267 meters) Canadian peak. The peak was later named Mount Kennedy after the presidential contender’s murder in 1968.

Whittaker was at Kennedy’s bedside when he died and was devastated by the assassination.

Whittaker grew up in Seattle and began climbing with his twin brother Lou Whittaker in the 1940s with the Boy Scouts. At 16, they summited 7,965-foot (2,428-meter) Mount Olympus, the highest peak in the Olympic Mountains west of Seattle, Jim Whittaker recounted in his memoir, “A Life on the Edge.” When they reached the town of Port Angeles on their way home, they found cars honking and people celebrating: World War II had ended.

Jim Whittaker once reflected that the beauty and danger of his sport sharpened the senses: “When you live on the edge, you can see a little farther,” he once reflected.

His achievements on the remote, snowy slopes of Mount Everest and nearby K2, the world’s second-tallest peak, assured him a niche in the record books. He was shocked when Lou decided to skip the 1963 Everest expedition in favor of opening a sporting goods store in Tacoma.

But Lou Whittaker wrote in his own book, “Lou Whittaker: Memoirs of a Mountain Guide,” that he still got to share in some of his twin’s glory by filling in when Jim got tired of attending parades or other events in his honor.

“Only our families and closest friends ever knew the difference,” he wrote.

Lou Whittaker died in 2024 at age 95.

Lou Whittaker, left, and his brother Jim Whittaker, right, pose for a portrait at Jim’s house, in 1980, in Seattle.

Ann E. Yow/AP/The Seattle Times

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Ann E. Yow/AP/The Seattle Times

Jim Whittaker led many additional climbs, including the 1990 Mount Everest International Peace Climb, which brought together climbers from the U.S., the Soviet Union and China “to demonstrate what could be accomplished through cooperation and goodwill,” the family statement said.

“Jim was a lifelong advocate for peace and believed deeply in the ability of shared challenges in the natural world to unite people across borders and ideologies,” it said.

Whittaker himself said one of his proudest moments came in 1981, when he led 10 handicapped climbers up 14,410-foot Mount Rainier. For them, he said later, “that was Mount Everest.”

Whittaker scaled Mount Rainier more than 100 times but did not take its familiar flanks for granted. The caprices of the weather, even on a comparatively modest mountain, “can turn a good climber into a beginner” in a matter of hours, he once noted.

Former Washington Gov. Jay Inslee called Whittaker’s legacy “just as impressive, and just as lasting, as Mount Rainier itself.”

“He pulled many a climber up the peak,” Inslee wrote in a social media post Wednesday. “He did the same for all our spirits. He still does.”

After years of risk on the world’s most dizzying pinnacles, Whittaker said in a 1980 interview that he hoped to “die in my sleep with the television on.”

He is survived by his wife of 52 years, Dianne Roberts; sons Bob, Joss and Leif Whittaker; three grandchildren; and one great-grandchild.

News

Video: Military Families Bear the Burden of War, Again

Published

17 hours ago

April 8, 2026

Press Room

Video: Military Families Bear the Burden of War, Again

KAYLA: Those are the ready-to-go care packages, I actually was going to the post office on Tuesday. KAYLA STEWART IS A MARINE VETERAN. HER DAUGHTER JULISSA IS SERVING IN THE U.S. – ISRAELI WAR IN IRAN, CURRENTLY DEPLOYED WITH THE NAVY IN BAHRAIN. KAYLA: …She loves harry potter so I found a harry potter tooth brush…her favorite gummies…so I got the easter version of those…….these will get to her way after Easter, unfortunately. KAYLA: Just seeing the world, that’s what she wanted to do – see the world. KAYLA: And she chose the Navy. So I’m actually really proud of her. KAYLA: But // Never in a million years would I have thought I would have had a child in a war time situation. WE’RE IN JACKSONVILLE, NORTH CAROLINA, OUTSIDE CAMP LEJEUNE, THE LARGEST MILITARY TRAINING HUB ON THE EAST COAST. FOR SOME MILITARY FAMILIES HERE, WAR IN THE MIDDLE EAST IS NOW IMPACTING A SECOND GENERATION KAYLA UPSOT: She’ll be happy to get when she opens those. KAYLA: THere’s my boot camp photo. KAYLA: September 11th happened when I was in boot camp. //they said America’s under attack. We didn’t know what that meant, you know, you’re a bunch of 18, 19 year old kids KAYLA: I pray for her safety everyday KAYLA: The Marine Corp taught me how to be numb. KAYLA: But at the same time, I’m a mom. // It takes a lot out of you. SCENE 2: BRUNCH SINCE THE WAR BEGAN, KAYLA HAS FOUND SUPPORT IN A GROUP OF MILITARY VETS, WIDOWS AND PARENTS OF ACTIVE DUTY SERVICEMEMBERS. (Group oohs and ahs in greeting) CARLA ARANA SERVED TWO TOURS IN IRAQ CARLA: It’s like history repeating itself. CARLA: In 2003//I fought a war, for this generation t CARLA: Why are we still in the same position? This has been going on since 2003. CARLA: Why are people dying? CARLA: What’s the value? And at what cost? CARLA: Not a lot of people know what it’s like to be mortared. Running for your life. . KAYLA: …My daughter- the last known location that I knew her to be, there was a bomb, a missile strike. So I’m like, okay, I’ve been here before, I’ve been in the military, I know how these things work, it’s radio silence right now. MICHELLE: That was scary. It still is scary. (nods with concern.) KAYLA: Somebody said “have you heard anything from your daughter? And I said, So, um. ‘No one has knocked on my door yet, so all is good.” MASTER STRINGOUT: 3:14:05 KAYLA: And I know your son is just getting started…. SCENE 3: AT HOME WITH MICHELLE MICHELLE: It’s war//No matter what you always have to be ready.//But//the iran war it’s my baby.//If it got to a point where had to go//it would crush me.//I don’t even want to think about it. MICHELLE: He wanted to make his dad proud MICHELLE WINDLE’S SON DESMOND RECENTLY ENLISTED IN THE NAVY. HER HUSBAND DENNIS, A MARINE, SERVED MULTIPLE DEPLOYMENTS TO THE MIDDLE EAST. MICHELLE: I’m a military widow. // That’s the flag they gave me when my husband passed away. HE DIED AT THE AGE OF 45 FROM CANCER RELATED TO CHEMICAL EXPOSURE THERE//IN THE REGION MICHELLE: This is Dez’s boot camp picture, and this is my husband’s boot camp picture…They were both 18. MICHELLE HASN’T SEEN HER SON SINCE THE CHRISTMAS HOLIDAY. MICHELLE: //I said, you know what? //I’m just going to keep my tree up because//this is scary//we don’t know what may happen//and just having it up makes me feel closer to them. MICHELLE: He said “mom//right now I’m safe.//but if I have to go, I have to go.” -END- 1:16:51 MICHELLE: He’s going to serve his county. And do what he can. MICHELLE: The Iran War..I think.. If it got to a point that he had to go….it would crush me.//I don’t even want to think about it. 04:14:24 MICHELLE: We don’t know what may happen. We don’t know. It is scary.