Physician Group Wants Medicare Advantage Reform

The nation’s largest physician specialty group is so frustrated by the harmful impacts Medicare Advantage (MA) plans have on their practices, it is asking CMS for major policy reforms in nine key areas.

In a position paper published in the Annals of Internal Medicine, the American College of Physicians urges CMS to strengthen oversight of plans — especially given that 54% of beneficiaries are enrolled in an MA plan.

ACP is particularly worried about efforts to let private companies eventually take over all of Medicare.

“Preserving a robust, publicly administered traditional Medicare program could help ensure health equity, continuity of care, and meaningful beneficiary choice,” the paper stated. “Privatization through unchecked MA expansion undermines these goals and risks transforming Medicare into a program where access to care is dictated more by administrative hurdles and profit motives than by patient needs.”

“Medicare Advantage is not just a niche alternative anymore, and it’s time we look seriously at policy reform,” author Brian Outland, PhD, director of regulatory affairs at ACP, told MedPage Today.

“It’s critical that we evaluate whether the program is delivering the right affordable care, equitable, high-quality, and patient-centered care that’s sustainable for beneficiaries, physicians, and taxpayers as a whole,” Outland said.

The paper highlighted an obstacle for MA enrollees who to get out of their MA plans and go to traditional Medicare so they’re no longer constrained to a network. They may wish to purchase a Medigap supplemental plan to pick up their 20% copayments, which can get expensive.

In most states, however, private Medigap companies prohibit beneficiaries with common pre-existing conditions from purchasing such plans or charge them much more in premiums.

The paper suggests that CMS can require “plans to offer enrollment annually without prior condition penalties,” thus giving “beneficiaries the choice to disenroll from MA.”

These are the nine highlighted concerns ACP wants CMS to address:

1. Ensure that traditional Medicare remains strong and sustainable by not replacing it with privatized plans. MA plans have numerous disadvantages and often require beneficiaries to stay within networks and get referrals or prior authorization, and specialist access is often limited, the paper said.

2. Prohibit downcoding of evaluation and management visit codes, a process in which a health plan assigns a code with a lower payment amount than the code the physician submitted. “Clinical documentation and coding determinations must be reviewed first by the treating physician, not altered through automated or artificial-intelligence-driven systems,” the paper stated.

ACP also called for standardizing MA plan supplemental benefits, such as coverage for dental, vision, and hearing services, which vary widely across plans leading “to major confusion among enrollees” who “struggle to evaluate and compare plans.” The agency should have greater oversight of how companies have increasingly leveraged “free gym memberships, transportation to health appointments, or meal services after hospital visits, as marketing tools to attract enrollees rather than prioritizing comprehensive care,” according to the paper.

These benefits “can come at the expense of fair and adequate physician reimbursements, potentially distorting clinician incentives.”

3. Require better oversight and regulation of deceptive MA marketing practices, including fines or star rating reductions, “to prevent misleading advertisements that confuse beneficiaries.” CMS recently dumped some MA plan marketing rules.

“Seniors and vulnerable persons with health needs have reported being misled by advertisements, mounds of paper mail, and sales agents who misrepresent plan benefits, resulting in unexpected out-of-pocket costs and difficulties accessing their physicians.”

4. Increase oversight of “unpredictable and burdensome” out-of-pocket costs and standardize reporting so beneficiaries have easy-to-understand information about what they’ll have to pay and will understand the “hidden expenses that add up quickly.”

In 2025, the MA maximum out-of-pocket was $9,350 for in-network services, and more for out-of-network care. This year, the cap is $9,250.

5. Implement a balanced risk adjustment system for MA plan capitated payments that enhances payment accuracy, prevents overpayments, and promotes transparency. In part because of MA plans’ practice of upcoding, Medicare paid $84 billion more to MA plans than if those same beneficiaries had received care through traditional Medicare in 2025, the paper noted.

In 2026, Medicare is expected to pay $76 billion more to plans than if those same beneficiaries were in traditional Medicare.

6. Streamline prior authorization processes with faster response times and minimized administrative burdens that delay care and add cost “without clear clinical justification.” The paper also wants CMS to require denials by artificial intelligence programs to subsequently undergo “direct review of the patient record by a qualified clinician.”

7. Require MA plans to offer comprehensive and accessible telehealth options, particularly for rural and underserved communities. However, ACP insists that telehealth should complement, not replace, in-person care.

8. Standardize reporting for how enrollees use supplemental benefits so the value of those services and impact on beneficiary health can be assessed.

“Historically, gaps in data reporting have made it difficult for policymakers, researchers, and beneficiaries to assess the effectiveness of these benefits. Without comprehensive reporting, there is no clear mechanism to determine whether MA plans are delivering on their promises or if enrollees are receiving equitable access to care,” ACP said.

9. CMS should impose regulatory oversight to prevent management service organizations and intermediaries from imposing restrictions that negatively impact patient access and continuity in MA models in which providers absorb full risk for all costs.

Currently, these organizations may “impose restrictive covenants that limit physicians’ abilities to contract with other entities for a defined period, sometimes up to 6 months.” These contract provisions disrupt patient care by forcing beneficiaries to find new physicians, which can be harmful for those with complex conditions, the paper stated.

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