Why Do Doctors Not Like Medicare Advantage Plan?

Every year during open enrollment season, millions of Medicare beneficiaries review their options and consider switching to a Medicare Advantage (MA) plan. These private insurance alternatives to traditional Medicare often come with lower costs, bonus benefits, and greater convenience.

However, behind the scenes, many physicians have grown increasingly wary of Medicare Advantage in recent years. While doctors want to deliver high-quality care for all their patients, the burdens imposed by MA plans have taken a toll.

A 2020 study from the Physicians Foundation found that 88% of doctors surveyed held an unfavorable view of Medicare Advantage. Their frustrations stem not from treating MA patients directly, but rather from dealing with the insurers administering these plans. Complex authorization requirements, claim denials, and low reimbursement rates have driven up administrative costs and burnout.

Specialists in particular struggle with MA plans. One cardiologist noted he spends over 3 hours per day navigating different plan rules and calling for approvals. The administrative duties have crowded out time with patients. Other research shows many specialists now refuse new MA members or have withdrawn entirely from some networks.

Primary care physicians face their own unique challenges. Getting behavioral health or minor procedures pre-approved stresses already overbooked schedules. One family doctor noted having to reschedule a surgery five times before an MA insurer finally agreed to cover it.

For patients, less access to their regular doctors poses problems. Few fully grasp the bureaucratic barriers physicians encounter with MA insurers on a daily basis either. This growing disconnect could undermine the doctor-patient relationship over time.

What is Medicare Advantage (Part C)

Medicare Advantage Plans are health insurance plans offered by private companies that contract with Medicare to provide Medicare Part A and Part B benefits. They are considered an alternative to Original Medicare and are growing in popularity, with over 26 million enrollees as of 2022. Medicare pays these private plans a set amount per enrollee to cover healthcare costs.

What is Original Medicare (Part A and Part B)

Original Medicare refers to traditional Medicare coverage administered directly by the federal government. It consists of Part A, which covers hospital stays and Part B, which covers doctor visits and outpatient services. Under Original Medicare, beneficiaries can see any provider in the country that accepts Medicare.

Medicare Advantage vs. Original Medicare

Medicare Advantage Plans must offer the same basic benefits as Original Medicare but can also include additional benefits like vision, hearing, dental, and wellness programs. With Original Medicare you can add a separate Medicare Part D Plan for prescription drug coverage, whereas Medicare Advantage Plans usually include this. A key difference is that Medicare Advantage Plans have provider networks and set rates, while Original Medicare allows you to see any provider.

Provider Differences Between Medicare Advantage and Original Medicare

• Original Medicare– Doctors deal directly with Medicare and can charge up to the Medicare-approved amount. No referrals are needed to see specialists.
• Medicare Advantage– Doctors must be in-network and follow utilization rules set by the private plan. Patients need referrals to see specialists and providers go through the plan for payment.

Disadvantages of Medicare Advantage Plans According to Doctor’s

Doctor Challenges

Many doctors complain about the hassles and disruptions that come with Medicare Advantage Plans. They cite issues like excessive prior authorization requirements, denied claims and coverage limitations, and limited referral networks as major pain points when dealing with these private plans. This causes frustration and administrative burdens for providers.

Network Limitations and Referral Requirements

Medicare Advantage Plans all have provider networks approved by Medicare. This means physicians must be contracted with specific plans to treat patients enrolled in them. Patients also need referrals from a primary care doctor before they can see specialists, unlike Original Medicare. These restrictions can limit which doctors and hospitals patients have access to.

Doctor Acceptance Between Medicare Advantage vs. Original Medicare

Surveys show that most physicians (around 93%) accept Original Medicare patients, while only 71% accept some Medicare Advantage Plans. This is often driven by lower reimbursement rates and more burdensome administrative tasks required by Medicare Advantage Plans.

Opting-Out or Limiting Participation

Due to frustrations with Medicare Advantage Plans, many doctors choose to opt-out of contracting with them entirely or limit the number of patients enrolled in certain plans they will accept. This shrinks provider networks and access for Medicare Advantage members compared to Original Medicare.

Reimbursement Rates and Administrative Tasks

Doctors often cite lower reimbursement rates from Medicare Advantage Plans compared to Original Medicare as a reason for not contracting with or limiting participation in certain plans. The additional paperwork required for prior authorizations, referrals, claims, and utilization review also place extra administrative burdens on smaller practices.

Ratings and Quality of Medicare Advantage Plans

Pros and Cons of Medicare Advantage Plans

Medicare Advantage Plans offer benefits like capped out-of-pocket costs, allowances for eyeglasses and hearing aids, and prescription drug coverage. However, they also restrict doctor choice, may not cover care while traveling, and can result in higher overall costs for sicker patients who use lots of healthcare services.

Conclusion

While Medicare Advantage Plans are gaining popularity among retirees, many physicians have issues working with them due to lower pay, narrow networks, and burdensome administration. This causes some doctors to limit or opt-out of seeing patients with certain Medicare Advantage Plans. Patients should weigh the pros and cons when choosing between Original Medicare or MA plans.

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FAQs

Why do some doctors not like Medicare Advantage Plans?

Some doctors may have concerns about the reimbursement rates and requirements imposed by certain Medicare Advantage Plans, which can impact the doctor’s ability to provide care and make a profit.

What is the difference between a Medicare Supplement and a Medicare Advantage Plan?

A Medicare Supplement, also known as Medigap, is a private insurance policy that works alongside Original Medicare to help cover out-of-pocket costs, while a Medicare Advantage Plan is an alternative way to receive Medicare benefits through a private insurance company.

Can I switch back to Original Medicare if I am enrolled in a Medicare Advantage Plan?

Yes, you have the option to switch back to Original Medicare during certain enrollment periods, such as the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period.

Are Medicare Advantage Plans a bad choice for everyone?

Medicare Advantage Plans can be a good choice for many individuals, but it’s important to carefully consider the specific benefits, costs, and network of doctors offered by different plans to determine if it is the right choice for your healthcare needs.

Do all Medicare Advantage Plans require me to pay my Medicare Part B premium?

No, some Medicare Advantage Plans may offer to cover all or part of your Medicare Part B premium, but it’s essential to review the details of each plan to understand the specific costs and coverage provided.

What should I do if I want to enroll in a Medicare Advantage Plan?

If you are eligible for Medicare, you can enroll in a Medicare Advantage Plan during specific enrollment periods, such as the Initial Enrollment Period, the Annual Enrollment Period, or a Special Enrollment Period if you meet certain qualifying criteria.

Why do some people prefer Medicare Supplement Plans over Medicare Advantage Plans?

Some individuals prefer Medicare Supplement Plans because they offer more flexibility in choosing healthcare providers and typically have lower out-of-pocket costs for services received outside the plan’s network of doctors.

What are some key factors to consider when comparing Medicare Advantage Plans?

When comparing Medicare Advantage Plans, it’s important to consider the plan’s network of doctors, coverage benefits, prescription drug coverage, cost-sharing requirements, and any additional benefits or limitations that may be important to your healthcare needs.

Are there situations when switching to a different Medicare Advantage Plan may be beneficial?

Yes, if your healthcare needs have changed or if you are dissatisfied with your current Medicare Advantage Plan, it may be beneficial to review and compare other available plans in your area to find a better fit for your specific needs and preferences.

Do Medicare Advantage Plans make it difficult to receive care when I get sick?

No, Medicare Advantage Plans provide coverage for necessary healthcare services when you get sick, but it’s essential to understand the plan’s rules, prior authorization requirements, and network of doctors to ensure that you can access the care you need in a timely manner.