3 Reasons Doctors Do Not Like Medicare Advantage Plans

Did your doctor groan or sigh when you mentioned you have a Medicare Advantage plan? Believe it or not, many doctors don't enjoy working with Medicare Advantage plans.

In this article, we'll share feedback from doctors on why they'd rather not bill Medicare Advantage plans.

Medicare Advantage Is For-Profit

Medicare Advantage plans are for-profit managed care plans.

With managed care plans, the insurance company's goal is to manage cost, utilization, and quality of care. Essentially, they're trying to give you the best care for the lowest possible price.

Oftentimes, that means disagreeing with a doctor's recommended treatment plan in favor of a less-expensive option. It also means having stricter provider networks.

In addition, Medicare Advantage plans have more cost-sharing with the beneficiary, which can put more financial risk on the provider.

All of these things can be very frustrating for doctors. Let's tackle each one.

1. Pre-Approval Process (Prior Authorizations)

One of the main ways managed care plans cut costs is through prior authorizations.

Private, for-profit plans – like Medicare Advantage plans – often require this pre-approval process for treatment plans, prescriptions, and even the ability to see certain specialists.

Why Doctors Dislike Prior Authorizations

The pre-approval process typically just slows things down by making providers jump through a series of hoops. That alone is frustrating.

But it gets worse – sometimes, the insurance company can flat-out deny a doctor's treatment plan, even if that doctor believes it's the best course of action for you.

This has happened to Dr. Jacob Sams, MD, a board-certified orthopedic surgeon at Decatur Orthopedic Center (DOC).

“I’ll never forget a patient that was told a bunch of misleading things, and when the time came for surgery, their MA plan basically said they hadn’t suffered enough, and they had to do several more weeks of therapy,” Dr. Sams explains.

It can be very frustrating when your doctor has expertise in their field and is confident in your best treatment plan, yet the insurance company says you have to try more inexpensive treatments first.

This very reason is why doctors like Dr. Sams prefer patients to have a Medicare Supplement instead of a Medicare Advantage plan.

Original Medicare vs. Medicare Advantage

As we've covered, Medicare Advantage plans are for-profit plans, so they take extra steps to ensure costs are low. One way they do this is by making beneficiaries try less expensive treatments before moving up to more expensive ones.

Original Medicare doesn't really work this way.

According to The Center for Medicare Advocacy, traditional Medicare has rarely required prior authorization. In fact, prior authorizations were not even allowed back in the day, but the law has been adjusted over time to allow prior authorizations for things like Durable Medical Equipment (DME) and physicians' services.

Even still, very few services and treatments require prior approval from Medicare.

For the most part, if you have Original Medicare with or without a supplement, you can see specialists, visit hospitals, get care out of state, and move forward with treatment plans without having to ask Medicare for permission first.

2. In-Network Referrals Can Be Challenging

Another reason your doctor may not be too fond of Medicare Advantage plans is they can have strict provider networks.

While MA networks are expanding – particularly PPO plans from national carriers – some plans can still be very strict and regional.

If your primary cary physician needs to refer you to a specialist, they may have a difficult time finding one that takes your insurance.

As an example, they may know a certain heart specialist is the best in your area, but if that physician does not accept your insurance, you may not be able to afford to see them. The doctor then has to find a different specialist that perhaps isn't as renowned.

In this way, Medicare Advantage plans can tie the hands of your doctor and stop them from referring you to the provider they believe is best.

Original Medicare vs. Medicare Advantage

Original Medicare with or without a supplement does not have provider networks. Providers and facilities do have to opt in to Medicare, but well over 90% do, so it's rare that you'll come across a provider or specialist that doesn't accept Medicare.

In general, the types of providers that don't accept Medicare include concierge doctors and psychiatrists. In fact, psychiatrists account for the largest share of specialists who opt out of Medicare (KFF).

Medicare Advantage plans, on the other hand, are network-based. You'll want to see in-network providers or you'll risk a higher coinsurance or even no coverage at all.

3. More Financial Risk

Last but not least, Medicare Advantage plans typically have very low premiums but higher out-of-pocket costs.

This means it's not very costly to simply have a Medicare Advantage plan, but it can get costly when you go to use your benefits.

As an example, if you have a hospital stay under a Medicare Advantage plan, you'll likely need to pay thousands of dollars out of pocket. That same hospital stay with Original Medicare and a Medicare Supplement would cost you only a couple hundred dollars.

The hospital knows Medicare and your supplement are going to pay for their portion, but they cannot guarantee that you will pay for your portion of the bill.

In fact, 100 million adults have healthcare debt, and nearly 1 in 4 Americans currently have a medical bill that's not paid.

A doctor would much rather you have an insurance plan that pays for the majority of your care rather than hoping that you actually pay your bill in a timely manner.

Conclusion

Medicare Advantage plans can be a fantastic fit for certain types of individuals, but there is no denying that many providers and facilities would rather you have Original Medicare.

Regardless of how your doctor may feel, it's important that you evaluate all of your options when it's time to enroll in Medicare.

Our team of licensed sales agents can run plan comparisons and quotes while keeping your needs and budget in mind. Reach out to us for no-cost, no-obligation help today.