Medicare Advantage plans are pretty popular among lawmakers and ordinary Americans. According to reports, they now enroll about 31 million people, representing just over half of everyone in Medicare.
However, among doctors and hospitals, it’s a different story. Across the country, healthcare providers are grumbling that claim denials and pre-approval requirements by Advantage plans are increasing.
Similarly, some hospitals and physician practices are so fed up they’re refusing to accept the plans. “The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, representing the for-profit hospital sector.
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Also, the industry’s largest lobbying group, the American Hospital Association, wrote to the Centers for Medicare and Medicaid Services. In the letter, they warned that some insurers seem intent on circumventing new rules passed by the Biden administration.
The Biden administration’s new rules, set to take effect in January, are in part a response to the OlG report. Also, enrollment for Medicare Advantage, traditional Medicare coverage, and stand-alone Medicare drug plans is open until December 7. Hence, these new rules aim to rein in some prior authorization and claim denials.
It’s not the first time we’ve seen disputes between insurers and providers, especially in negotiations with employer-sponsored plans. However, the focus now on Medicare Advantage “seems different.”
According to David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy, hospitals and doctors are becoming “much more vocal” about their frustrations with some of the insurers’ cost-control efforts.
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Consequently, hospitals are threatening to cut ties with Advantage Plans offered by United Healthcare and WellCare Health Plans Inc. Baptist Health in Louisville, for example, threatened to cut ties with these organizations from January unless they come to terms.
According to the system, the plans “routinely deny or delay approval or payment for medical care recommended by your physician.” The system’s medical group, with nearly 1,500 physicians and other providers, left Humana’s network in September.
In addition, two large medical groups affiliated with Scripps Health said they would no longer contract with Medicare Advantage insurers. Consequently, more than 30,000 people are seeking new doctors in San Diego. Revenue “is insufficient to cover the cost of patient care we provide,” they said.
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Besides these, prior approval is another significant point of friction. According to KFF, some Medicare Advantage enrollee plans require the insurer to sign off in advance for some care. Although insurers say that the process ensures treatments are coordinated and appropriate, healthcare providers disagree.
According to KFF, healthcare providers submitted over 35 million requests for prior approval for Medicare Advantage enrollees in 2021. However, they denied over 2 million of them. For the minority of patients who appealed (11 percent), 82 percent won a full or partial overturning of the insurers’ decision.
In addition, people with job-based insurance and those who buy theirs through the Affordable Care Act also engage in prior approval. Similarly, there are lots of complaints about them, too.
Conversely, Medicare beneficiaries can choose the traditional, government-run program with limited prior approval and claim denials. Doctors and hospitals have plenty of gripes about how much conventional Medicare pays them. However, they spend less time fighting over medical decisions.
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