The Centers for Medicare and Medicaid Services (CMS) is implementing a revised strategy to address the issue of insurers increasing profits through upcoding in Medicare Advantage plans. The agency has announced changes to its risk adjustment model, which determines payments to insurers based on patient health conditions. This new approach will utilize more recent data to calculate risk scores, aiming to curb practices that inflate diagnoses and lead to higher reimbursements.
The updated methodology incorporates data from 2018, replacing the previous reliance on older datasets. CMS officials state that this change is intended to improve accuracy in assessing patient health risks while reducing opportunities for insurers to exploit coding practices for financial gain. The move comes amid growing scrutiny over how some insurance companies have used upcoding—reporting more severe diagnoses than patients actually have—to increase payments from the federal government. By using fresher data, CMS aims to better align payments with actual patient needs and reduce excessive spending within the Medicare Advantage program.
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Date: February 9, 2026
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