Why Do Doctors Dislike Medicare Advantage?

Our goal is to give you the tools and confidence you need to improve your health and finances. Although we may receive compensation from our partner insurance companies, whom we will always identify, all opinions are our own. CoverRight Inc. and CoverRight Insurance Services Inc. (NPN: 19724057) are collectively referred to here as "CoverRight".

Have you ever wondered why some doctors seem hesitant about Medicare Advantage plans despite their popularity among enrollees? Do doctors like medicare advantage plans?

Medicare Advantage is widely embraced, with 30.8 million enrollees in 2023 making up over half (51 per cent) of eligible Medicare beneficiaries, as reported by KFF. Despite its popularity, some doctors have reservations about Medicare Advantage plans. So why do doctors not like medicare advantage plans?

Many often wonder if one option provides better care than another when choosing between Original Medicare and Medicare Advantage. Choosing between Original Medicare and Medicare Advantage is an informed decision. While neither is definitively better, you can weigh their pros and cons to make the right choice. Let’s explore Medicare Advantage from the provider’s and enrollee’s perspectives.

What is Medicare Advantage?

Medicare Advantage (Medicare Part C) is an alternative way to receive Medicare coverage through private health insurance companies approved by the Centers for Medicare and Medicaid Services (CMS). Unlike Original Medicare (Part A and Part B), Medicare Advantage plans are bundled ‘all-in-one’ plans that often include Part D (prescription drug coverage) and extra benefits like vision, hearing, dental care, and wellness services.

One key difference between Medicare Advantage and Original Medicare is their structure. Original Medicare is a fee-for-service program where the government pays directly for the healthcare services you receive. In contrast, Medicare Advantage plans are managed care plans, which means the insurance company gets a fixed amount from Medicare to provide your care. This can result in differences in cost-sharing, provider networks, and coverage rules between the two types of plans.

Another difference is the availability of out-of-pocket maximums. While Original Medicare does not have a cap on out-of-pocket costs, Medicare Advantage plans must have a yearly limit on how much you pay for covered services.

Why Do Doctors Not Like Medicare Advantage Plans?

Here are the reasons why some doctors may not prefer Medicare Advantage plans over Original Medicare.

1. Managed Care Cost Management

Medicare Advantage plans are a type of health insurance plan that aims to control healthcare costs while ensuring that beneficiaries receive high-quality care. These plans achieve this by negotiating rates with healthcare providers, establishing networks of preferred providers, and implementing utilization management techniques to ensure that healthcare services are used efficiently. This approach can lead to disagreements over treatment plans between doctors and insurance companies. Insurance companies may even prefer less expensive treatment options, which may not align with a doctor’s recommendation for optimal care.

2. Stricter Provider Networks

Medicare Advantage plans often have stricter provider networks compared to Original Medicare. This can limit the specialists the patients can see, as they must choose from within the plan’s network. Many patients wonder, ‘Does Medicare require a referral to see a specialist?’ Indeed, doctors require Medicare for this purpose and may find it challenging to refer patients to specialists if their insurance plan has a strict network with limited coverage.

3. Referral and Pre-Authorization Requirements

As previously discussed, the question ‘Do Medicare patients need referrals?’ is a common inquiry; indeed, doctors need Medicare. However, there are challenges specific to Medicare Advantage pre-authorization and referrals. While these requirements aim to improve the coordination of patient care, they can also delay necessary tests or treatments. Additionally, these requirements may put some decisions about care in the hands of the insurance company rather than the patient’s provider.

4. Financial Risk for Providers

Medicare Advantage plans typically have certain out-of-pocket costs for patients. If a patient requires expensive medical services, the financial burden may fall more heavily on the provider if they cannot pay their share. This financial risk can concern doctors, especially in light of the significant healthcare debt many Americans already face.

5. Prior Authorization Process

Medicare Advantage plans often require prior authorization for treatment plans, prescriptions, and specialist visits. This process can be time-consuming and frustrating for doctors, as it may delay necessary care. Insurance companies can also deny a doctor’s treatment plan, even if the doctor believes it is the best course of action for the patient.

Medicare Advantage Plans: A Beneficiary’s Perspective

Medicare Advantage plans, known for their comprehensive coverage, are favoured by many beneficiaries for their added benefits and cost-saving potential. These plans often include coverage for services beyond what Original Medicare offers, such as vision, dental, and prescription drug benefits, providing a more holistic approach to healthcare. Medicare Advantage plans typically have lower out-of-pocket costs, including annual spending caps, which can offer financial security and predictability.

Despite these advantages, enrollees may encounter challenges with Medicare Advantage plans. One common issue is the requirement to use providers within the plan’s network, which can limit choice and access to certain specialists or hospitals. Additionally, managing referrals and prior authorizations can be complex and time-consuming, potentially delaying necessary care.

Pros and Cons of Medicare Advantage Plans

Medicare Advantage plans offer a range of benefits and cost-saving opportunities, but they also come with limitations and potential challenges. Let us look at the pros and cons of this plan:

Pros:

Comprehensive Coverage: Medicare Advantage plans often offer more benefits than Original Medicare, including prescription drug coverage and additional services like vision, dental, and hearing.
Lower Monthly Premiums: In many cases, Medicare Advantage plans have lower monthly premiums than Original Medicare with a separate Part D plan.
Cost Savings: Copayments with Medicare Advantage plans are often lower than coinsurance with Original Medicare, providing potential cost savings.
Care Coordination: Medicare Advantage plans allow for better care coordination among healthcare providers, potentially leading to improved health outcomes.
Additional Benefits: There are certain Medicare Advantage plans with additional benefits, both medical and non-medical, such as prepaid cards for medications, health supplies, and caregiver support. These plans may also offer non-medical benefits like gym memberships, meal discounts, and transportation services.

Cons:

Limited Provider Networks: Medicare Advantage plans may have limited doctor and hospital networks, making it harder to find certain specialists or receive care outside the network. For instance, a 2023 Health Affairs study revealed a concerning statistic: approximately half of the counties reviewed did not have a single Medicare Advantage-participating psychiatrist.
Out-of-Network Costs: If you need to see a doctor outside your plan’s network, you may have to pay extra for that care.
Prior Authorization Requirements: Medicare Advantage plans often require prior authorization for certain services, which can lead to delays or denials of care.
Travel-related Restrictions: If you travel frequently or have a second home in another part of the country, you may face challenges finding in-network providers and paying extra for out-of-network care.

Ready to make the right choice for your Medicare coverage? Explore your options with CoverRight. Our resources and personalized guidance can help you navigate the complexities of Medicare Advantage and Original Medicare. Let us be your trusted partner in finding the coverage that suits you best.

FAQs

I don’t like my MA plan. Can I switch?

If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you have the option to switch to another Medicare Advantage Plan (with or without drug coverage) or return to Original Medicare (with or without a drug plan) within the first three months of having Medicare Part A and Part B. If you are currently enrolled in a Medicare Advantage plan and wish to switch to traditional Medicare, you should contact your current plan to cancel your enrollment. After cancelling, you can call 1-800-MEDICARE (1-800-633-4227) to enrol in traditional Medicare. You can consult CoverRight for expert guidance on transitioning from Medicare Advantage to traditional Medicare.

How can I view/change doctors drugs?

Medicare Advantage and Part D plans must notify you of any changes they make during the plan year, including changes to your provider network or formulary. If you wish to view or change your doctor or drugs, contact your plan directly or review your plan’s Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents. If your plan makes formulary changes during the year, such as covering a generic drug instead of a brand-name drug, they must give you 60 days’ notice or provide a 60-day transition refill. For guidance on navigating your Medicare options, consult with CoverRight.