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
“The Medicare Supplement products are NOT cheap.”
It depends. Like I just said my Part F premium is just over $110/month.
That’s so that the nonprofit hospitals can write off Z90% of care as a “loss” for tax purposes.
My mother in law had mma Humana South Florida
I handled her claims never an issue
There were plenty of claims!!!
https://www.propublica.org/article/health-insurance-denials-breaking-state-laws
Claim File Helper
https://projects.propublica.org/claimfile/
How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them
https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims
But you have to admit that the core of medicine has made a valiant effort to cash in, too. Why does an audiologist charge ten times what a drugstore does for essentially the same hearing aids?
Every po-dunk town used to have an eye doctor who made a fat living working 4 short days and playing golf on Wednesdays until somebody figured out eyeglasses didn't have to cost an arm and a leg.
And the duplication of million dollar diagnostic machines in service areas is another cost-driving force. We have a good friend wh is a Doc in private practice, and he loves to talk about the two medical monstrosities at war in our service area, but they do everything but fight a price war.
I’m pretty sure the formularies (covered drugs in different categories) vary among Part D plans but have to verify that. When I picked my Part D plan three years ago I thought that my selected plan was better for high-tier drugs but again have to confirm. I seem to recall that all Part D plans have to cover a given number of drugs in each category but which ones and maybe copay amounts is up to them.
I swear to God that no one really knows everything until a claim is filed.
iirc, I think I read something recently about proposed legislation would make buying prescriptions from Canadian pharmaceutical operations illegal for US citizens.
Any chance this could happen?
Yeah, but they don’t have discretion to deny a Part D claim if the drug is listed on the formulary. It is either covered or it isn’t.
Any chance this could happen?
I think it is illegal, but not seriously enforced. I really don't know enough to have a strong opinion. If Canadian taxpayers subsidize the price, that is not fair. I can't see why some US sellers do not have a process to bid on the meds, so there is competition. Big Pharma does seem to have license to steal. It is probably just another example of corruption, sad to say.
Sounds good, but the dosage or the need may be argued.
My broker also refuses to sell Medicare Advantage.
From quick reading it appears that a denial can come only from 1) Need to use less expensive drugs first (step therapy) - which is clearly documented in the contract or 2) Because the plan covers only 30 per month, etc., and not more, or 3) Because prior authorization wasn’t obtained for certain drugs (this is the area where they may have some discretion — it isn’t a factor for common drugs).
bookmark
They are out there! Use an agent/broker who you can contact after the dotted line is signed. Do not buy on the internet. MHO
Regarding insurance in general, claim denials are very often in error, though, and never in the policyholder’s favor. A certain amount of people will just pay, right or wrong, out of frustration with the bureaucracy.
you’re lucky, F nolonger exists...
Thanks. I am dreading the research- it’s so confusing. I don’t really have any peers to ask and have no idea where to find someone knowledgeable and reliable who isn’t a sales person. I just wish they’d give us the $ instead in something like the form of an HSA type card so I could continue to do WTF I want, when and where I want. I don’t even know if I’m on my husband’s plan if I still have to apply yet or not!! This is a PIA
One thing I forgot to mention, I am also receiving Entyvio infusions (had 3 so far), and I have not had to pay a penny for those, Thank God.
Yes, it is an enormous PITA. The reason I decided on the Part G supplement was that I could always change to an Advantage plan later, but it’s not always possible to do the reverse, as another poster commented earlier.
You might be able to talk to someone at Medicare, too, not just insurance agents. Good luck.
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