Sauer: Mass. must get ahead of health care fraud

August 17, 2026 - 12:06

If policymakers drag their feet, Medicare Advantage's waste, fraud, and abuse problems could erode public trust, drive up taxpayer costs, and threaten the long-term viability of the program. That is the warning from state officials and watchdogs who say Massachusetts cannot afford to wait for federal fixes that may never come.

Medicare Advantage, the private insurance alternative to traditional Medicare, now covers more than half of all beneficiaries nationwide. In Massachusetts, enrollment has climbed steadily, and so have concerns about improper billing. Audits and whistleblower cases have repeatedly flagged patterns of upcoding, where insurers submit higher-cost diagnoses to boost payments, even when patient records do not support the claims. The result is billions in overpayments each year, money that comes straight from the federal budget and, ultimately, from taxpayers.

State leaders argue that Massachusetts has both the authority and the responsibility to step in. The state already runs its own health insurance marketplace and has strong consumer protection laws. What it lacks is a coordinated strategy to review Medicare Advantage claims, share data with federal investigators, and penalize bad actors. Without that, the problem will only deepen as the population ages and more seniors choose private plans.

The stakes go beyond dollars. Every dollar lost to fraud is a dollar not spent on actual patient care. And when trust in the program erodes, seniors may delay needed treatment or avoid preventive services altogether. That harms health outcomes and drives up costs in other parts of the system, like emergency rooms and nursing homes.

Some advocates want Massachusetts to create a dedicated fraud unit within the state attorney general's office, modeled after the Medicaid fraud control units that already exist. Others suggest requiring Medicare Advantage plans to report more detailed billing data to the state, making it easier to spot suspicious trends. Both ideas have merit, but neither will happen without political will.

The clock is ticking. Federal oversight has been inconsistent, and recent court rulings have made it harder for the government to claw back improper payments. If Massachusetts waits for Washington to act, the problem will keep compounding. The state has a chance to lead, to set a standard for transparency and accountability that other states could follow. But that chance will not last forever.