Georgia hospital system. his two medical groups in San Diego;The other is in and near Louisville, Kentucky. One-third of Nebraska hospitals. Across the country, health care providers are offering some Medicare Advantage plans even as coverage provided by private insurers increasingly replaces traditional government programs for the elderly and disabled. refuses to accept.
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KFF Health News
As of this year, private insurers have persuaded just over half of all Medicare beneficiaries, or nearly 31 million people, to sign up for their plans instead of traditional Medicare. In addition to drug coverage, these plans typically include additional benefits such as vision and dental benefits, and many have low or even no additional monthly premiums compared to traditional Medicare. .
But the surge in enrollment has also created friction between insurance companies and the doctors and hospitals they pay to treat beneficiaries. Experts who monitor the insurance market say hospitals and medical organizations are struggling with the payment rates imposed by Medicare Advantage plans, the onerous requirements for prior authorization to provide care and too many subsequent claim denials. This is causing more and more conflict.
Insurers say they are simply trying to control costs and avoid inappropriate care. The controversy is now gaining even more attention during Medicare's annual public offering period, which runs through Dec. 7.
Patients are stuck in the meantime. Those whose preferred doctors and hospitals deny coverage may have to switch their Medicare Advantage plans or revert to a traditional program. Although it may be difficult Or it may not even be possible if you switch to get a so-called “Medigap” policy, which covers some of the cost-sharing requirements of a traditional plan.
For example, more than 30,000 San Diego-area residents are looking for a new doctor after two large medical groups affiliated with Scripps Health announced. they won't sign anymore Partnering with Medicare Advantage insurance companies.
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“Insurance companies that run Medicare Advantage plans are pushing doctors and hospitals to extremes,” he said. chip kernpresident and CEO of the American Hospital Federation, which represents the for-profit hospital sector.
AHIP is the lobbying arm of the insurance industry. said in a February letter. The Centers for Medicare and Medicaid Services says prior authorization and other similar reviews reduce “inappropriate care by identifying unsafe, low-value care, or care that is inconsistent with current clinical evidence.” He argued that this would protect patients.
AHIP spokesman David Allen said in an email that enrollment in Medicare Advantage plans is increasing because people like them, citing research conducted by an organization. Coalition supported by AHIP.
The majority of people were satisfied with their plans and the access to care provided, he wrote.
So far, the dispute does not appear to be centered around a particular insurer, region, or provider, but both the largest Medicare Advantage insurers, United Healthcare and Humana, have It is one of the insurance companies that has been canceled.
Baptist Health in Louisville, Kentuckysaid in a statement that all nine of its hospitals, as well as its clinics and physician groups, are severing ties with the company's Advantage plans. united healthcare and Wellcare Health Plans Co., Ltd.Unless a deal is reached, it will begin in January.
“Many Medicare Advantage plans routinely deny or delay approval or payment for medical care recommended by patients' physicians,” Baptist Health said in a statement.
The system's medical group consists of approximately 1,500 physicians and other health care providers. I left Humana Networked in September.
In a similar move, Southeast Georgia Health System, a Brunswick, Ga.-based company with two hospitals, two nursing homes and a network of physicians, signed a contract with Centene Corporation's WellCare Medicare Advantage Plan this fall. warned that it would end in December. ,Quote what it said It was years of “inadequate insurance payments and unwarranted denials.”
Health systems are at risk of discontinuing Advantage plans.
In some cases, a health system's threat to abandon an Advantage plan or an insurer's threat not to include a provider in its network is a negotiation tactic intended as a lever to win concessions on payment rates or other issues. in some cases. And some were resolved. For example, at Adena Regional Medical Center in Ohio, said in september It will eliminate Medicare Advantage plans offered by Elevance Health, formerly known as Anthem Inc. I have reinstated them below.Additional negotiations.
Still, some hospital and policy experts say the dispute could be the start of a trend.
I said, “This doesn't seem right.” david lipshutzHospitals and physicians are becoming “more vocal” about their dissatisfaction with some cost-control efforts by Medicare Advantage insurers, said the Medicare Advocacy Center's deputy director and senior policy attorney.
“There are serious issues emerging that are plaguing providers, such as payment suspensions and reviews. I wouldn't be surprised if we start to see more of this backlash as the Medicare market becomes more concentrated in a small number of insurers. .” Don Berwick saidchairman emeritus and senior fellow at the Institute for Healthcare Improvement, and a former CMS administrator.
Plan availability varies by county, but on average Medicare beneficiaries can choose from 43 plans. According to KFF. UnitedHealthcare and Humana account for about half of his Advantage plan enrollments nationwide.
According to research, Medicare Advantage costs taxpayers more per beneficiary than traditional programs. But the plan is so popular that it has the support of many lawmakers, especially Republicans.
Last year, the Department of Health and Human Services inspector general issued a review of some of Advantage's plans. Interview refusal For the care that should be provided under Medicare regulations.
The report identifies prior authorization requests (the requirement to get the OK from an insurance company before certain treatments, procedures, or hospitalizations) and insurance claims where an insurance company denies payment for all or part of a treatment that has already been performed. We investigated the denial of the claim.
Member of Parliament recently requested Additional information from Advantage Insurance Company regarding the factors used to make such determination.
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CMS proposes rules This month, it will cap commissions for brokers selling Medicare Advantage plans and require more information about how the plans' pre-approval programs affect certain low-income enrollees and people with disabilities.
Lipschutz said the HHS inspector general's investigation may have encouraged hospitals and doctors to be more candid.
The Office of the Inspector General discovered Thirteen percent of denied treatment requests and 18 percent of denied claims the company investigated were for covered treatment. Partly in response to this report, the Biden administration announced rules scheduled to go into effect in January that would require Medicare Advantage plans to provide “the same medically necessary care” as traditional programs. All Advantage insurers are also required to review their policies annually to ensure they are consistent with traditional programs.
The American Hospital Association praised the administration's actions but questioned whether they were enough.in letter sent last month The hospital lobby group told CMS that its members “have been contacted by some individuals.” [insurers] Either they have no plans to change their protocols or they have “changed the terminology and procedures in rejection letters in ways that appear to circumvent the intent of the new rule.” The letter called for “rigorous oversight” by CMS.
Allen, the AHIP spokesperson, did not respond to a request for comment on the AHA's letter.
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