Posted on 11/24/2023 10:47:42 AM PST by buckalfa
Medicare Advantage provides health coverage to more than half of the nation's seniors, but a growing number of hospitals and health systems nationwide are pushing back and dropping some or all contracts with the private plans altogether.
Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.
"It's become a game of delay, deny and not pay,'' Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker's. "Providers are going to have to get out of full-risk capitation because it just doesn't work — we're the bottom of the food chain, and the food chain is not being fed."
In late September, Scripps began notifying patients that it is terminating Medicare Advantage contracts for its integrated medical groups, a move that will affect more than 30,000 seniors in the region. The medical groups, Scripps Clinic and Scripps Coastal, employ more than 1,000 physicians, including advanced practitioners.
Mr. Van Gorder said the health system is facing a loss of $75 million this year on the MA contracts, which will end Dec. 31 for patients covered by UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Centene's Health Net and a few more smaller carriers. The system will remain in network for about 13,000 MA enrollees who receive care through Scripps' individual physician associations.
"If other organizations are experiencing what we are, it's going to be a short period of time before they start floundering or they get out of Medicare Advantage," he said. "I think we will see this trend continue and accelerate unless something changes."
Bend, Ore.-based St. Charles Health System took it a step further and was not only considering dropping all Medicare Advantage plans, but also encouraged its older patients not to enroll in the private plans during the upcoming enrollment period in October. The health system's president and CEO, CFO and chief clinical officer cited high rates of denials, longer hospital stays and overall administrative burden for clinicians. Ultimately, the health system has decided to remain in network with four MA carriers and will not renew contracts with three.
"We recognize changing insurance options may create a temporary burden for Central Oregonians who are currently on a Medicare Advantage plan, but we ultimately believe it is the right move for patients and for our health system to be sustainable into the future to encourage patients to move away from Medicare Advantage plans as they currently exist," St. Charles Health CFO Matt Swafford said.
"I feel terrible for the patients in this situation; it's the last thing we wanted to do, but it's just not sustainable with these kinds of losses," Mr. Van Gorder added. "Patients need to be aware of how this system works. Traditional Medicare is not an issue. With these other models, seniors need to be wary and savvy buyers."
Here are 13 more recent instances of hospitals dropping Medicare Advantage contracts:
In October, the Nebraska Hospital Association issued a report detailing how Medicare Advantage is "failing patients and jeopardizing Nebraska hospitals," 33% of which do not accept MA patients. The report cited negative patient experiences, post-acute placement delays, and administrative and financial burdens on hospitals that accept MA patients.
York, Pa.-based WellSpan Health will no longer accept Humana Medicare Advantage and UnitedHealthcare-AARP Medicare Advantage plans starting Jan. 1. UnitedHealthcare group MA PPO and Humana employer PPO MA plans will still be accepted.
Greenville, N.C.-based ECU Health said it anticipates it will no longer be in network with Humana's Medicare Advantage plans starting Jan. 1.
Raleigh, N.C.-based WakeMed went out of network with Humana Medicare Advantage plans in October. According to CBS affiliate WNCN, the plan provides coverage to about 175,000 retired state employees. WakeMed cited a claims denial rate that is "3 to 4 times higher" with Humana compared to its other contracted MA plans.
Zanesville, Ohio-based Genesis Healthcare System is dropping Anthem BCBS and Humana Medicare Advantage plans in 2024.
Brunswick-based Southeast Georgia Health System will terminate its contract with Centene's WellCare Medicare Advantage plan on Dec. 8. The system said it started negotiations with the carrier after years of "inappropriate payment claims and unreasonable denials."
Nashville, Tenn.-based Vanderbilt Health went out of network with Humana's HMO Medicare Advantage plan in April.
Fayetteville, N.C.-based Cape Fear Valley Health dropped UnitedHealthcare Medicare Advantage plans in July.
Corvallis, Ore.-based Samaritan Health Services ended its commercial and Medicare Advantage contracts with UnitedHealthcare. The five-hospital, nonprofit health system cited slow "processing of requests and claims" that have made it difficult to provide appropriate care to UnitedHealth's members, which will be out of network with Samaritan's hospitals on Jan. 9. Samaritan's physicians and provider services will be out of network on Nov. 1, 2024.
Cameron (Mo.) Regional Medical Center stopped accepting Cigna's MA plans in 2023 and plans to drop Aetna and Humana in 2024. It plans to continue Medicare Advantage contracts with UnitedHealthcare and BCBS, the St. Joseph News-Press reported. Cameron Regional CEO Joe Abrutz previously told the newspaper the decision stemmed from delayed reimbursements.
Stillwater (Okla.) Medical Center has ended all in-network contracts with Medicare Advantage plans amid financial challenges at the 117-bed hospital. The hospital said it made the decision after facing rising operating costs and a 22% prior authorization denial rate for Medicare Advantage plans, compared to a 1% denial rate for traditional Medicare.
Brookings (S.D.) Health System will no longer be in network with nearly all Medicare Advantage plans in 2024, with the exception of Medica. The 49-bed, municipally owned hospital said the decision was made to protect the financial sustainability of the organization.
Louisville, Ky.-based Baptist Health Medical Group went out of network with Humana's Medicare Advantage plans in September, Fox affiliate WDRB reported. The system will also go out of network with UnitedHealthcare and Centene's WellCare on Jan. 1 without a new agreement in place
I don’t know why links sometimes post poorly for me.
They're hard to figure. I have Part D but it's next to worthless on some drugs. Other more common drugs (ones that have gone beyond the patent time limit, I guess) are free.
Where they make out is when their expense on certain drugs gets too high they reclassify it into another category requiring you to pay more for your part.
I also think government, like Biden and his plan that went into effect to make insulin cheaper just raised the cost on other drugs significantly. Politics.
In the end, I just count prescriptions I have as out-of-pocket and have the Part D only because I am required to have as part of Medicare. In any case, I still treat MA or MediGap insurance like the plague because of all pitfalls they have if you don't closely follow the rules and precoordination.
It's a contender.
When we had our daughter, we didn’t have insurance and we didn’t get to use Medicaid because I had a job. Had to pay cash, up front.
“Anyone with a computer these days who does not immediately Google “nutrition and supplements to help condition XXX” after a diagnosis is missing important help.”
I agree. And always dig deeper than the first couple of pages returned by a Google search. Most of the first returns you receive will be of articles discounting the use of supplements. Use a different search engine and look for other sources.
Decades ago, when people grew their own food, they also received the nutrients from the minerals in the soil. The same goes for chemically treated water versus bored wells. Now everything is so sterilized we do not get those important vitamins and minerals that are so vital to our bodies.
It’s my belief that a little dirt is good for you and now everything is way too clean. For instance, during Covid everyone was sanitizing their hands and everything they touched. In my opinion that was harmful to our immune systems, and especially those of young children.
When my children were toddlers, they spent a lot of time outside and I’m sure more than one handful of dirt went into their mouths. They were seldom sick although after the third time to the hospital for the eldest and his propensity for breaking his arm (climbing trees), I did worry child services would be called. My b-i-l and his wife washed and boiled everything and their children were not allowed outside without shoes and long-sleeved shirts. After the birth of their first child, when we went to visit we had to take off our shoes outside and wash our hands immediately upon entering their home. Their children’s play-time was always carefully monitored and organized. One of them were sick and at the doctor’s office or in the hospital at least once a month. To this day, they all have a pale and unhealthy look to them. The boys can’t even grow a beard at age 30. My boys would have to shave twice a day if they wanted a clean-shaven face.
That was long ago and far away .... Growing up for me, everybody paid out of pocket. But that was because we didn't have to sell the farm to do it.
“””The ‘billed rate’ and the paid rate by medicare AND insurers with agreements are vastly different. From what I’ve seen in my own bills from hospitals the actual payoff is less than 10% of the billed amount.”””
This needs to be repeated again and again.
Far too many people only look at what a hospital or doctor billed Medicare for a procedure and fail to look at what Medicare or an insurance company actually paid for the procedure.
True. This was in 1980.
You can blame inflated medical costs on Government meddling, lawyers and non workers who want free everything in exchange for votes.
Here’s a seldom seen factoid - Obama’s wife got a job at a University Medical Hospital when he was a Senator. It paid $380K/year IIRC. Her job was to convince some non paying potential patients to seek treatment elsewhere.
These people actually exist?"
At one time I was close to being an expert on what they now call the Revenue Cycle: insurance coverage, utilization review,case management, and billing/reimbursement. That was part of my responsibilities during my 34 year hospital career. I was able to successfully navigate the healthcare bureaucracy during my early retirement. Now not so much, and I even try to stay abreast of the industry.
I was just billed $616 by local hospital for nuclear stress test. My cardiologist wants a different test now, but sorry, not going to get it. I called my insurer and they paid a ton too.
“Funny...the hospital where I get my care,a very famous one,just started offering its own Medicare Advantage plan.”
It will be interesting to see what the pre-authorization denial rate is for its own claims, own program.
Yes, it appears we’ve gone full circle. Insurance to pay rising medical costs. Costs go up to meet supply $$ because insurance pays. Insurance goes up. Uncle Sugar steps in to help with costs. Costs soar like eagles run amok to meet the supply of $$. Things snowball, but it isn’t snowing any more.
I have to make this decision soon and am terrified of screwing it up.
Then it blows up, and we get NHS.
in 2002 I had a 5 way bypass in Anaheim Cardio Hospital. They kept me 4 days before surgery, because they wanted the blood thinner out of my system So I was there in cardio ICU 7 days, including 3 days after a 7 hour surgery.
Cost? 225,000 I paid nothing, including for physical rehab.
*******
OK good, did you have Medicare Advantage or Supplemental?
“I’m on Medicare A & B. Provider is Kaiser. Isn’t everything taken care of?”
No, you are without non-hospital coverage, generally speaking. And without outside of hospital prescription drug coverage, again, for the most part.
Unfortunately they are limiting our ability to take independent care of ourselves/ our health by increasingly censoring our searches and in some cases preventing us from finding certain information altogether.
The Medicare Supplement products are NOT cheap.
The Medicare Advantage products are cheap. The MA stuff is marketed very heavily and aggressively; after all, can’t you trust Joe Namath? (LOL)
Also, the commissions that the MA products generate for insurance agents entice them to recommend that product over others. HECK!!! MA will pay the insured retiree additional cash per month to be on the program. So, no out of pocket amounts owed (except for the Medicare premium deducted from Social Security check).
Letting the Federal government make financial and healthcare decisions for the taxpayers is a very sad turn of events.
That’s right. That’s why if you only have Medicare A and B, you need a supplemental plan to pick up that 20%. Hubby has Mutual of Omaha as his supplemental plan. He is staying away from MA plans.
I had a friend years ago that signed up for Medicare Advantage. He ended up in a non-network hospital after having a heart attack. He received a $100k bill that was not covered by MA. Lesson learned.
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