Double-Check that Your Providers Are, and Will Be, In-Network for 2025
A recent HealthLeaders article titled “Providers Are Fed Up With Medicare Advantage” by Marie Defreitas (Sept. 9, 2024) begins: “[a]cross the country, more providers are opting to drop Medicare Advantage (MA) plans creating a new trend within the healthcare landscape.” Listing a number of major health systems that have announced they will no longer contract with MA plans, the article cites to a survey conducted by the Healthcare Financial Management Association (HFMA) which found that “19% of health systems have stopped accepting a Medicare Advantage plan [and] 61% are planning to or are considering.” The HFMA survey also found that “82% of health systems are experiencing higher denials than pre-pandemic levels.”
Highlighting arguments often made by provider organizations that end contracts with MA plans, the HealthLeaders article states:
Providers often argue that Medicare Advantage plans impose restrictions that can hinder patient care. Low reimbursement rates, complicated billing [processes] and stringent pre-authorization requirements have pushed CFOs to their boiling point. The administrative burden and financial strain associated with MA plans is simply not worth it for many health systems.
While provider groups are increasingly refusing to contract with Medicare Advantage plans, MA and other health insurance enrollees can encounter problems accessing providers who – at least in theory – are part of a plan’s contracted network. In his HEALTH CARE un-covered blog, Wendell Potter recently published an article titled “Important Reads: New Reporting Details Ghost Networks and Fighting Denials” (Sept. 10, 2024) which discusses a common problem faced by health insurance plan enrollees:
when they finally reach out for help, they all too often discover a grim reality: Many of the providers listed in their insurer’s directory simply don’t exist or aren’t accepting patients. This isn’t a minor oversight; it’s what’s known as a “ghost network” and it leaves countless people stranded when they need care the most.
Potter highlights several articles describing this (and other health insurance) problem(s), including ProPublica’s “‘I Don’t Want to Die’: Needing Mental Health Care, He Got Trapped in His Insurer’s Ghost Network” by Max Blau (Sept. 8, 2024), which documents the plight of a marketplace plan enrollee who “bought a health insurance plan thinking it would deliver on its promise of access to mental health providers. But even after 21 phone calls and multiple hospitalizations, no one could find him a therapist.”
The Annual Enrollment Period (AEP), which allows Medicare beneficiaries to make changes to their Medicare Advantage and/or Part D plans for the following year, starts on October 15th. If you are enrolled in a Medicare Advantage plan or are considering doing so, make sure to confirm that your providers are part of, and will remain in, the plan’s network for the coming year. Unfortunately, there is no guarantee that an MA plan’s network will not change during the calendar year.
September 11, 2024 – D. Lipschutz