Austin Amestoy: We’re continuing our coverage about health care options for seniors. It’s the time of the year when many are considering Medicare enrollment options. MTPR health care reporter Aaron Bolton is back to talk more about Medicare Advantage — Medicare plans run by private insurance companies. We previously chatted about some of the tradeoffs Montanans should consider when shopping for these health care plans.
But Aaron, you’re here to talk about why some providers aren’t taking Advantage plans. And that means patients might be seeing fewer care options. What's happening?
Some providers are limiting Medicare Advantage coverage
Aaron Bolton: There’s no hard data on just how many providers have limited the number of Medicare Advantage plans they accept or walked away from that coverage altogether.
But Barry Olson, who runs a physical therapy practice in Missoula, says it’s happening.
“I would see these patients from Missoula in Deer Lodge, in Polson, in Hot Springs because they couldn’t get a bed in Missoula because they wouldn’t be accepted because of their [Medicare] Advantage plans.”
Costs and administrative hassles are turning providers away
AA: Why are providers walking away from these plans?
AB: There are two key reasons: they’re losing money treating these patients, and working with Medicare Advantage can be an administrative hassle.
Olson says he loses about $20 for every Medicare and Medicare Advantage patient. Olson still takes Advantage plans and hopes the financial issues won’t force him to walk away.
“If we stopped taking the Medicare or Medicare Advantage patients, we’re eliminating my own family members from the services we provide. But at some point, we need to decide, it’s a matter of survival,” said Olson.
AB: And this isn’t just some health care providers in Montana no longer accepting Medicare Advantage plans.
Trish Newman is with KFF, a nonpartisan health research group.
“Some are hanging in, but there are more and more stories, mostly anecdotal, of hospitals saying 'we’re not going to participate, we’re not going to be in network,'” Newman says.
AA: So, reimbursement is an issue for both Medicare and Medicare Advantage. In our last conversation we talked about providers saying Advantage plans excessively use prior authorizations and that can delay or prevent patients’ care. Are providers saying they are walking away from these plans because of that issue?
AB: Yea, that is part of the reason they are dropping these plans or at least considering it.
According to Bob Olson, president of the Montana Hospital Association, “We’ve got some clinicians that are reporting about a quarter of their clinical time on the phone with various payers.”
AB: That’s time they could be spending treating patients and the time spent working through all that paperwork costs money.
Hard data is limited. Here's what we dug up
AA: You said that there isn’t hard data on this trend, so we can’t say how much this is happening, right?
AB: Correct. I’m not aware of anyone directly tracking this. I wanted to get a sense of the scope of the problem by surveying providers in Montana. We weren’t able to survey hospitals, something we hope to do in the future.
But I did survey nursing homes about Medicare Advantage. We were able to get responses from nearly half of the 45 homes in the state.
Six facilities said they have stopped taking certain Medicare Advantage plans, and another six said they were considering dropping plans. Humana and United Health were the number one plans cited in the survey.
I reached out to both companies about this, but neither responded.
Prior authorizations and payment delays deter some providers
AA: And are providers not accepting these plans because of the prior authorization and payment issues?
AB: Yeah. But they also say some plans aren’t paying them at all or won’t pay fast enough.
One facility dropped a plan they said owed them $150,000 and it took three years before that insurance company was willing to negotiate. That’s the most severe example, but several facilities said these insurance companies owed them up to $50,000.
AA: Is there anything that can be done about these plans being slow to pay these nursing homes?
AB: I reached out to the Montana Auditor’s Office. It said it doesn’t regulate Medicare payments. This is something that falls to the federal government.
Here’s Gretchen Jacobson with the Commonwealth Fund, a health care research group.
“They have to pay 95% of their bills within 30 days, and any days past that point, they have to pay interest."
AB: If plans don’t pay their bills within 60 days, federal regulators can reduce the amount of money they pay to these plans. It’s unclear whether any plans in Montana have faced those penalties.
Jacobsen says it’s hard to say how broad this slow or no-pay issue is among Medicare Advantage plans, but says it’s something federal regulators should keep an eye on.
AA: Ok, well let’s leave it there. Aaron, thanks for your reporting.
AB: Thanks for diving into the weeds with me Austin.
