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 like to watch the old 60s / 70s TV shows, and the cable channels which broadcast them are flooded with commercials for Medicare Advantage Plans. They feature a bunch of old has-beens who must be desperate for a buck; they talk up these plans, hoping to snatch the elderly consumer (”Well, if Joe Namath is recommending this...”). I always either mute them or change the channel.
Perhaps there are a lot of scams out there. For a while I was getting at least 3 calls a day from people offering “senior advice”. Since I have KP, I immediately hung up and erased their phone number. This did not slow down the calls until last week. Now only one call a day or less. Hopefully after the Dec. cut-off date they will stop altogether.
I think this is what DS is talking about. Correct me if I am wrong.
“exhibit A: COVID vaccination.”
I think Exhibit A was Covid itself. When they realized it didn’t kill enough of the elderly, enter Exhibit B — the vax
not sure if that applies to the rest of the alphabet.
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Oh boy there sure is and I’m paying it. The Gov does nothing for free - Part A is mostly a joke without some form of other insurance. MA has been the best thing going. But now ...?
Scripps is huge in San Diego dropping Heathcare Advantage plans (HMOs Medicare), 27,000 people all on medicare. Says insurance too often refuses to approve what doctors recommend and they don’t like the pay schedule.
I have 7 specialists with scripps including Nephrology, Cardiology, Gasterointerology, Endocronology, and opthomologist. For the last 18 years. Numerous procedures, stents, etc.
Saved by being in a PPO instead of an HMO. So staying. Scripps will bill insurance they will pay most of it, with a slight increase in co-pay. Can’t remember why I signed up for a PPO 25 years ago, but glad I did.
if you go with original Medicare.
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once retired, there is only medicare.
NO—He means PART C & Part D.
Part C has many other things it will pay for-—Don’t know the list.
Part D is for drugs.
Part A still pays 80%.
EXACTLY what OBAMA wanted.
I know; see my post #12.
Just because its advertised on TV, does not mean that plan is available in your area.
You always have the option of comparing plans in your area, and so do your due diligence.
An even bigger surprise-—The health PROVIDER you have been going to for years-—NOW is ONLY ACCEPTING some OTHER PLAN.
YOUR plan==travel over 40 miles —one way to “New facility” & start all over with NEW DOCTORS, etc.
Just Hospital right?
“Joe Namath”
I think JJ Walker does some of the advertisements as well...
“dynomite”....
I don’t pretend to understand it but it sure smells like some sort of scam.
one necessary operation can easily cost $100K, and at 80%, that leaves you with a $20K bill ... before the hospital bill, associated drugs, therapies, etc kick in.
AND-—IF you die ‘early’—they do NOT have to pay your Soc Sec checks every month.
Jim Noble: Systemically, however, MA programs are causing catastrophic harm and they should be discontinued soon.
thinden: how much pressure do you think the illegal migrants are putting on the health care system costs? & normal insurance premiums?
Not just the ILLEGALS, thinden.....the elephant in the room, that hasn’t been mentioned by the leftist, lying media and CDC is.... it’s likely the D@MN $hots causing the ‘catastrophic harm’ on our healthcare system.
All. By. Design.
“Discontinue, soon” ... spit ...
Jim was one of the big proponents of the jabs, IIRC, so there’s that.
Just Hospital right?
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My plan pays the first 10 days with copay of $295 a day. After 10, no copay. Just Hospital.
Yep, he's another one of those losers who hawk these plans. Another one which makes me cringe is the one with Tom Selleck selling investment scams.
I’m taking the state employee plan which is better coverage for higher premiums.
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