If Your Medicare Advantage Plan Is Under Investigation: Practical Steps for Beneficiaries

If Your Medicare Advantage Plan Is Under Investigation: Practical Steps for Beneficiaries

Hook: If you’ve heard your Medicare Advantage (MA) plan is under investigation, it’s natural to feel anxious—about your care, your medical bills, and whether you’re being billed for conditions you never had. The stakes are real: recent enforcement actions, including a landmark settlement in January 2026, show regulators are cracking down on improper billing and upcoding in MA. But being informed and organized gives you power. Below is a clear, practical checklist you can use today to protect your care, your records, and your wallet.

Why this matters now (2026 context)

Federal and state enforcement ramped up in late 2025 and into 2026. In January 2026, the Department of Justice announced a major settlement in which Kaiser Permanente agreed to pay $556 million to resolve allegations it submitted inflated Medicare Advantage payments by reporting conditions patients did not have. That case—one of the largest involving MA billing—signals growing scrutiny from CMS, the DOJ, and state regulators.

At the same time, the National Association of Insurance Commissioners (NAIC) updated its 2026 leadership and priorities, reflecting stronger state-based oversight of insurers. What this means for beneficiaries: regulators are paying attention, and you should too. If your plan is under investigation or you suspect errors, you can take concrete steps to protect yourself.

Top-line checklist (act now)

1. Get and audit every Explanation of Benefits (EOB) or claim summary
2. Keep a dated record of all visits, tests and communications
3. Check diagnoses and procedure codes on bills
4. Compare provider notes to billed diagnoses
5. File complaints, appeals and escalate if needed
6. Consider plan switching windows and eligibility
7. Know when to seek legal or advocacy help

1. Audit claims: how to get the paperwork and what to look for

Start by gathering everything your plan and providers have sent you for the past 12–24 months: EOBs from your MA plan, itemized provider bills, and any letters showing claim denials or adjustments.

Where to request documents

• Your Medicare Advantage plan: Ask for an itemized Explanation of Benefits (EOB) and copies of claims submitted to Medicare. Plans must provide EOBs upon request.
• Your health care provider(s): Request an itemized bill, a copy of the medical record or chart notes for specific visits, and the diagnosis and procedure codes used (ICD-10 and CPT/HCPCS codes).
• CMS and Medicare resources: Call 1-800-MEDICARE for guidance on EOBs and appeals, and use Medicare.gov to check your plan’s performance and past enforcement actions.

What to check on each claim

• Dates of service: Verify the visit date matches your calendar and medical notes.
• Provider name and location: Confirm the clinician listed is the one you actually saw.
• Diagnosis codes (ICD-10): Look for conditions you were never diagnosed with or that don’t match the visit reason.
• Procedures/tests billed: Ensure tests and procedures were actually done and were medically necessary. If you need help understanding lab or home-test trends, consider resources on the evolution of home review labs in 2026 that explain how testing and reporting have changed.
• Duplicate or excessive billing: Watch for the same service billed multiple times or services that seem inappropriate for your condition.

“Fraud on Medicare costs the public billions annually, so when a health plan knowingly submits false information to obtain higher payments, everyone — from beneficiaries to taxpayers — loses.” — U.S. Attorney (quoted during the 2026 settlement)

2. Keep visit records and build an audit trail

Organization is your best defense. Create a simple, dated log that includes:

• Visit date and time
• Clinician and facility
• Reason for visit in your words
• Diagnoses or findings the clinician told you (verbatim if possible)
• Any tests done and their results
• Follow-up instructions and prescriptions

Keep electronic copies of all mail, EOBs, bills and provider notes. Screenshots of patient portal visit summaries are valid documentation. For guidance on organizing digital paperwork and searchable folders, consider approaches from a 2026 playbook on collaborative file tagging and privacy‑first sharing. If a provider’s note lists a diagnosis you don’t recognize, ask for clarification and a corrected record if appropriate.

3. Check diagnoses on bills: what upcoding looks like

Upcoding is when a provider or plan lists a more severe diagnosis or higher-paying procedure than what was actually treated. The 2026 Kaiser case alleged systematic upcoding to raise MA risk scores and payments. As a beneficiary, you can spot red flags:

• New, chronic conditions appearing on bills without any clinical discussion or treatment notes (e.g., multiple chronic disease codes added without supporting tests).
• Complex diagnosis codes for routine, brief visits (e.g., coding for heart failure or dementia when the visit was for an upper respiratory infection).
• Multiple comorbid conditions coded in a single visit without documentation showing they were addressed.

If you find suspect codes, ask your provider: "Can you show me the notes that support this diagnosis code?" If the provider cannot produce supporting documentation or corrects the record, ask them to resubmit corrected claims to your plan. If you’re tracking patterns across many members or clinics, there are operational playbooks about managing complex reviews and escalations that can provide a framework for community reporting and organization (operations playbook).

4. Appeal and grievance steps: timelines and templates

If you find an incorrect charge, start with the plan’s grievance and appeal process. Medicare Advantage plans must give beneficiaries clear instructions and timelines for appeals.

Key timelines (typical, but check your plan)

• Initial coverage decisions: plan must notify you and give a reason.
• Internal appeal: you often have 60 days from the date on the denial notice to file, though some denials have shorter windows; act promptly.
• Expedited requests: if waiting risks your health, you can request an expedited/fast appeal.

What to include in an appeal letter

Use a clear, factual tone. Include:

• Your full name, Medicare number, plan ID and contact info
• Date(s) of service and claim number(s)
• Specific billing error(s) and why the billing is incorrect
• Attached evidence: EOBs, provider visit notes, test results, and a short timeline
• Requested remedy (e.g., remove diagnosis X, correct claim, rescind collection letter)

Send appeals by certified mail or through the plan’s portal and keep proof of submission. If the plan denies your appeal, you can request a second-level review (external review) by an independent entity and ultimately appeal to CMS.

5. When and how to switch plans (enrollment periods in 2026)

Switching plans may be the right move if you lose confidence in your plan’s billing practices or if you worry about continuity of care. Know the windows:

• Annual Election Period (AEP): Oct 15–Dec 7 — switch between Original Medicare and MA, or change MA plans for the next plan year.
• Medicare Advantage Open Enrollment Period (MA OEP): Jan 1–Mar 31 — if you are already in an MA plan, you can switch to another MA plan or return to Original Medicare (with a Part D drug plan).
• Special Enrollment Periods (SEPs): For qualifying life events (e.g., moving, losing employer coverage), timing varies.

Before switching, check these items:

• Plan network: Will your doctors and hospital be in-network?
• Formulary and costs: Are your medications covered and at what tier?
• Star ratings and enforcement history: Look for recent enforcement actions, consumer complaints, or public settlements (such as the 2026 Kaiser case).
• Risk to continuity of care: If in active treatment, coordinate transfers carefully to avoid gaps.

6. Escalation: regulators, consumer help and legal options

If your appeals are unsuccessful or you see systemic issues, escalate.

Who to contact

• Your state insurance department: File a complaint—state regulators handle consumer protection for insurers. Your local oversight and reporting can mirror the kind of community-driven governance featured in discussions about neighborhood governance and local tech for approval workflows.
• Medicare: Use 1-800-MEDICARE or the Medicare Beneficiary Ombudsman to file complaints and get help navigating appeals.
• CMS: File a complaint online about your plan’s behavior or billing practices.
• NAIC: While the NAIC doesn’t handle individual claims, state commissioners who participate in NAIC committees are currently prioritizing oversight in 2026—reporting to your state commissioner helps aggregate concerns.

When to seek legal help

Consider an attorney when:

• You’ve suffered substantial out-of-pocket loss and the plan will not correct it.
• Your credit is at risk because of erroneous collection actions tied to disputed claims.
• You suspect systemic fraud (e.g., widespread upcoding across many members).
• You are a whistleblower with documentation of illegal billing practices—attorneys experienced with the False Claims Act can evaluate potential claims.

Look for lawyers who specialize in Medicare law, False Claims Act litigation, or health care regulatory matters. If cost is a concern, contact your state legal aid, or a local senior legal assistance program—many offer consultations at low or no cost.

7. Advanced strategies and tools (2026 and beyond)

As oversight increases, more consumer-facing tools and services have emerged. Consider these advanced strategies:

• Medical bill audit services: For complex or high-dollar cases, paid medical billing auditors or patient advocates can review claim histories and demand corrections. If you’re organizing a larger review, look to practical operational frameworks for coordinated reviews (operations playbook).
• Use technology: Apps and services now allow you to track medical claims, store EOBs and flag discrepancies automatically.
• Connect with patient advocacy groups: Organizations that focus on seniors and Medicare can amplify complaints and offer resources.
• Monitor enforcement trends: Follow CMS enforcement notices and DOJ settlements (like the January 2026 settlement) to identify patterns and at-risk plans.

Real-world example: what one beneficiary did

Mrs. R., a 72-year-old on an MA plan, noticed an unexpected diagnosis code for congestive heart failure on an EOB after a routine annual visit. She kept a handwritten log of visits, requested the clinician’s chart notes, and discovered the code had been added after an unrelated phone call. She filed an appeal with her plan, attached the clinic notes and her visit log, and the plan corrected the claim. Mrs. R. also filed a complaint with her state insurance department—her single case contributed to a larger review of coding practices at that clinic.

Red flags that demand immediate action

• Multiple new chronic diagnoses appear suddenly on EOBs without supporting care.
• You receive bills for services you never received.
• Your provider’s notes do not match the codes on the submitted claim.
• The plan notifies you of sudden changes to your coverage or provider network tied to a billing investigation.

Practical templates and next steps (starter checklist you can use today)

1. Collect: Request EOBs and itemized provider bills for the last 24 months.
2. Log: Start a dated visit log and scan all documents to a folder.
3. Compare: Match visits to claims and highlight discrepancies (date, diagnosis, procedure).
4. Ask: Request supporting clinical notes from providers for flagged claims.
5. Appeal: Submit an appeal to your plan within 60 days of a denial; include supporting notes and your log.
6. Escalate: If unresolved, file complaints with your state insurance department and 1-800-MEDICARE.
7. Consider: If you’re unsatisfied and within an enrollment window, compare plans and prepare for switching during AEP or MA OEP.

What to expect from regulators in 2026

Expect continued enforcement and transparency. CMS and the Department of Justice are signaling stronger oversight of risk-adjustment coding and payment integrity. State insurance commissioners—through NAIC leadership in 2026—are prioritizing consumer protection. That means more audits, more recoveries, and hopefully clearer patient-level disclosures. For beneficiaries, this trend should yield improved accuracy over time, but in the short term it also means pay attention: audits can reveal erroneous coding that directly affects you.

Final takeaways: protect your care and your records

• Be proactive: Don’t wait for a bill you don’t recognize—monitor EOBs and patient portal notes regularly.
• Document everything: Even simple visit logs and screenshots can be decisive evidence.
• Use your appeal rights: Plans must have grievance processes—use them and escalate timely.
• Know your windows: AEP and MA OEP are your opportunities to switch if trust breaks down.
• Escalate when necessary: State regulators, CMS and legal counsel are available if errors have serious financial or health consequences.

Call to action

If you’re enrolled in a Medicare Advantage plan and worry about billing accuracy, start your audit today: request your most recent EOBs, create a simple visit log, and compare diagnoses on bills to your medical notes. If you find discrepancies, file an appeal with your plan and, if needed, contact 1-800-MEDICARE and your state insurance department. If you’d like a printable checklist or a sample appeal letter template you can customize, download our free packet or contact our patient advocacy partners for a consultation.

Related Reading

• Beyond Filing: The 2026 Playbook for Collaborative File Tagging, Edge Indexing, and Privacy‑First Sharing
• The Evolution of Home Review Labs in 2026: From Pop‑Up Tests to Micro‑Fulfilment
• Royal Mail Industrial Action Update: What Customers Should Expect This Week
• Micro‑Documentaries & Patient Education: How Homeopaths Convert Trust in 2026
• Apple + Gemini: Implications for Enterprise Assistants — A Vendor Selection Playbook
• Choosing the Right Editor for Low-Overhead Tasks: Notepad vs Advanced Editors
• Ambient RGBIC Interior Lighting: Cheap Lamp Tricks Adapted for Your Cabin
• Guillermo del Toro: A Cinematic Life — Filmography, Influences, and the Dilys Powell Honor