MGMA shops draft bill to curb automatic downcoding in Medicare Advantage

The Medical Group Management Association (MGMA) has drafted legislation that would prohibit Medicare Advantage (MA) plans from automatically downcoding physicians' claims. It is shopping the bill to congressional staff from both parties, Madison Hynes, M.P.P., an associate director of government affairs at MGMA, said Sept. 27 at the MGMA Annual Conference 2026 in San Antonio.

"I would say in the last year, that's been the thing we've heard from members most, or most often," Hynes said of downcoding. "It's been the biggest increase that we're hearing from members on."

MGMA worked with its attorneys in Washington to write the bill, and Hynes has been taking it to congressional staff, particularly in the House doctors caucus. "There's a lot of understanding of the challenges of downcoding, especially the automatic nature of it," she said.

The version MGMA prefers is a clean prohibition. "We would love just for all automatic downcoding to be prohibited across Medicare Advantage, and hopefully that would again trickle into some of the commercial stuff as well," Hynes said.

MGMA also wrote a fallback. "Obviously, we're up there on the Hill, but so are all the big insurance companies," Hynes said.

Under that version, a plan could downcode automatically only if it proves a physician has upcoded above a specified rate. The plan would have to notify the physician, and the downcoding policy could last no more than 90 days before the physician returns to standard review.

Many of the MA and commercial downcoding policies Hynes reviews say they target bad actors who have been shown to upcode, she said, but they don't explain how that is determined. Physicians and practices often don't know they have been placed under a downcoding policy at all, she said.

The draft names AI and other algorithms. An attendee said practices are seeing more automatic downcoding and claim denials driven by artificial intelligence.

"I do not think that is a top regulatory priority for this administration specifically," Hynes said. She said Congress has shown more interest than regulators in transparency on the issue, while the regulatory side is moving slowly.

Hynes said congressional staff have shown a lot of interest in the outright ban. She said MGMA expects "quite a big pushback on the Hill from the big insurers" either way.

The MA backdrop

MA now covers more than 55% of Medicare beneficiaries. In MGMA's 2026 regulatory burden report, 90% of responding practices said they had seen a shift toward MA among their patients, and 79% of those said the shift has had a negative effect on their practice.

Three of the top five burdens practices cited in the report are tied exclusively to MA. MGMA's slides also flagged downstream effects for large systems that run MA plans or take on delegated risk.

MGMA supports two other bills aimed at how MA plans pay physicians: the Medicare Advantage Improvement Act and the Prompt and Fair Pay Act. Between them, they would set a floor for MA payment at traditional Medicare rates and impose deadlines for paying claims, Hynes said.

On prior authorization, MGMA is pushing the Improving Seniors' Timely Access to Care Act, which Hynes said has 290 House cosponsors.

MA reform is unlikely to top Congress' agenda before the Dec. 11 funding deadline, Hynes said. But congressional offices have shown growing support for it, and it "will likely be a priority for the coming Congress," she said.

Medical Economics is in San Antonio at the MGMA Annual Conference, Sept 27-30, celebrating 100 years of MGMA, attending sessions and speaking with industry leaders. Follow our coverage on our MGMA conference page.