Can Doctors Refuse Medicare Advantage Plans?

When it comes to Medicare Advantage plans, networks are critical. They determine your doctors, hospitals, specialists, pharmacies, and more.

In this blog, we’re going to look at Medicare Advantage in more detail to explain networks, situations where coverage could be denied, and how understanding your plan’s coverage can save you time and money.

Disclaimer: Medicare Allies is not affiliated with Medicare or any other government agency. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

What is a Medicare Advantage network?

Medicare Advantage networks determine where you can go to receive covered services.

Original Medicare doesn't have networks, but Medicare Advantage (MA) plans are very different. MA plans are offered by private insurance carriers, and they are network-based.

In other words, to save the most money and get the most out of your plan, you will need to select providers and facilities within your network.

When exploring your Medicare Advantage options, you will want to ensure you look at the network and find out if your doctors, hospital, and pharmacy (if getting drug coverage) are covered before enrolling.  

• Want to learn more about Medicare Advantage networks? Check out this network-focused blog post that goes into more detail about what they are and how they work.

Do Medicare Advantage plans let you see any doctor you want?

While your plan won’t restrict your right to choose your care providers, they will likely deny coverage or charge a higher fee if you select a doctor outside of your plan’s network. Your plan will offer a list of doctors in your provider network to help you save on costs within your plan.

Most networks offer a good selection of primary care doctors, but specialists can be a little more selective. This is true of specialists generally, as many require referrals or reviews of your medical history to ensure their fee will be covered by your plan. The problem lies when there are limited specialists in your area and they do not accept your insurance or are not part of your plan’s network.

Why do some doctors not accept Medicare Advantage?  

Some doctors choose not to work with different insurance companies. Insurance companies and providers must agree on the prices paid for different services. If they don't see eye-to-eye, the physician may choose not to accept that particular company's plan.

Beyond reimbursement rates, there can be disagreements about treatment plans and testing. Medicare Advantage is managed care, meaning the plan can decide if a less expensive treatment should happen before a more expensive one. This can be frustrating for providers who want to skip ahead to a more expensive, potentially more effective, treatment but are stopped from doing it by the insurance company.

According to the American Medical Association, the average medical office spends over 16 hours per week completing prior authorization paperwork, which is meant to help you get the coverage you need for certain services (cited on Very Well Health).

Because of these two main reasons, some providers choose not to work with different insurance companies. If you are looking for a doctor, you should review your plan’s network to see if the doctor you want accepts your plan.  

Do specialists accept Medicare Advantage?

Many specialists accept Medicare Advantage plans, but not all.

If you are worried about needing specialists and not having sufficient network selections, speak with a licensed insurance agent to explore your options. Our team here at Medicare Allies is always available to help.

We can help you determine a Medicare Advantage option with the providers you need or recommend an alternative option. If network restraints are a driving concern for you, it may be time to explore Medicare Supplements in more detail, as they are not network-based.

Can Medicare Advantage plans drop providers at any given time?

It is possible for a provider and carrier to opt to part ways, but it will not happen out of the blue. You, as the patient, will be given a warning. In this unusual circumstance, your medical provider should provide notice alerting patients to network changes.  

Coverage change notices can include signs in the office and written notice sent to your home by their billing department. Special coverage exceptions can happen in these events, particularly for terminal patients. If you do not qualify for an exception, continued treatment from that provider would be paid for out of your wallet.

Is it hard to find Medicare Advantage providers?

It is easy to find providers for most major Medicare Advantage plans. These plans come from national companies with strong service reputations, which means they will have strong coverage networks.

This is especially true of PPOs, which typically offer wider networks and are more forgiving of out-of-network services.  

Another thing to bear in mind is networks are constantly growing. Many Medicare Advantage plans expand their coverage to new areas each year, which attracts more providers. Medicare Advantage networks are constantly expanding, which means greater access to more providers. Many plans have robust networks with provider groups nationwide.  

When looking for a provider or exploring Medicare Advantage options, the important thing is to look at networks and see if your current doctors are in your area and if they offer a variety of specialist options for those who might need focused care.  

Conclusion

Understanding Medicare Advantage networks is essential to using your coverage plan. When seeking care, review your plan’s network to see if your doctor is in your network. And if not, now is the time to explore changing your coverage plan to one with more options.  

The Annual Enrollment Period is open from October 15 through December 7. Schedule an appointment with one of our agents today to discuss your coverage and learn more about your options for the following year.

Our team of licensed insurance agents can also help you verify your in-network providers to help you make informed coverage decisions. We are here to help!