The V28 Model Balances the Differences Between Medicare Advantage and Traditional Medicare Plans

This is not new news. It goes back for years. Medicare Advantage costs more than Medicare. Much of this is due to price setting. Advantage plans will receive overpayments of approximately $76 billion Center for American Progress above what the same care would cost in traditional FFS Medicare. This is nothing new. It has been going on for years. New risk adjustment model V28 levels the difference between Traditional and Advantages Medicare plans.

“Medicare Advantage Upcoding Shows the Power of Corporate Influence,” CEPR, June 2026

Chart taken from: “Medicare Advantage overpayments will total $76B this year: MedPAC,” Healthcare Dive

The unfortunate truth is the moneyed interests buying influence in government can also rob the American taxpayer blind with just little to no repercussions and do so with steadfast support from “public” representatives.

On June 1, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report  detailing how Medicare Advantage organizations (namely, insurance companies) submitted false diagnosis codes to reap higher government payments. More specifically, the report estimates that there were $461 million in overpayments in 2021 alone for falsely applying high-risk acute stroke diagnosis codes to patients whose medical conditions did not warrant this code.

This concept is not new. For years, government and outside groups have estimated billions in overpayments to Medicare Advantage plans coming from those insurance companies making patients appear sicker than they actually were with improper diagnosis codes. This practice is called upcoding.

If a regular American goes into a store and gets caught stealing, they would have to give all stolen items back and would go to jail. So, what is the punishment for these MA companies?

Very little. For years, the government has known about upcoding and billions in overpayments, yet they let the practice continue with no incarceration for corporate executives.

In a few individual cases, the Department of Justice (DOJ) has reached settlements with MA companies to resolve claims of upcoding. In January, the DOJ got Kaiser Permanente to agree to pay $556 million. Yet, the company allegedly stole over $1 billion, so they still made close to half a billion dollars in the end. In March, Aetna agreed to pay roughly $118 million to resolve similar claims. It is unclear whether this amount is less or more than the taxpayer dollars lost to upcoding.

More importantly, the government admittedly succumbed to industry pressure and dropped its plans to stop financing future overpayments. The HHS OIG report recommends that the government “implement[s] a procedure to prevent overpayments.”

Earlier this year, the Trump administration proposed keeping payments to MA insurers flat. The Medicare Payment Advisory Commission (MedPAC) estimated $76 billion in overpayments this year, so limiting the annual payment rate increase to 0.09 percent was a means to not give even more money than required.

Yet, the Centers for Medicare and Medicaid Services (CMS) reversed this initial proposal, increasing the payment rate by 2.48 percent instead, which translates to an increase of roughly $13 billion. During congressional testimony, HHS Secretary Robert F. Kennedy Jr. admitted that meetings with the MA insurance companies were instrumental in boosting the payment rate.

On top of this blatant corporate influence, the Republican Congress explicitly rejected addressing Medicare Advantage overpayments in its “One Big Beautiful Bill Act” (OBBBA). This was in spite of the fact that Republicans alleged that the purpose of the legislation was to rein in federal spending. However, the OBBBA supposedly achieved this by cutting nearly $911 billion from Medicaid over ten years and around $187 billion from the Supplemental Nutrition Assistance Program (SNAP).

On top of the fact that the OBBBA will actually increase the federal debt by trillions due to tax cuts for the wealthy, the bill had no provision for cutting overpayments to MA insurers. While Republican Senator Bill Cassidy from Louisiana introduced the No Upcode Act to rein in upcoding, the Trump administration and congressional leaders omitted this proposal from the bill.

The reason why Medicare Advantage companies get away with robbing the American taxpayer is quite clear: money. From 2020-2024, seven top insurance companies that had Medicare Advantage plans spent over $330 million on lobbying the federal government. At least half of the lobbyists that the seven companies employed in 2024 lobbied on Medicare Advantage.

While lobbying disclosures do not reveal the specific issue being lobbied on for each dollar spent, reporting from multiple outlets has documented the extensive lobbying campaigns during the Trump administration to prevent reining in over-payments.

Unlike Medicare Advantage companies, lower-income Americans who rely on Medicaid for health coverage and SNAP for food assistance don’t have the same ability to spend hundreds of millions on lobbying and campaign contributions. They did not have the resources to buy the concern of the Trump administration and Republican Congress, while the health insurance companies did.

The latest HHS OIG report certainly does its job in exposing yet another example of corruption in the Medicare Advantage program. The problem is that — unless corporate power is challenged — nothing will be done about it.

New new risk adjustment model/program V28: “Decoding Medicare Advantage Coding Intensity,” KFF