32 health systems dropping Medicare Advantage plans | 2024
"Learn about the growing trend of hospitals and health systems dropping Medicare Advantage plans due to administrative challenges, including prior authorization
List of Hospital Systems dropping MA for 2025
- Thread starter Millwood
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InsuranceGuy29
Guru
- 803
They're so full of shit...lol. If it was about prior authorizations, then they'd ban ALL insurance, as roughly 95% of people have insurance with some sort of prior authorizations, and they're just fine.32 health systems dropping Medicare Advantage plans | 2024
"Learn about the growing trend of hospitals and health systems dropping Medicare Advantage plans due to administrative challenges, including prior authorizationwww.beckershospitalreview.com
It's about MONEY. Insurers switched to a "healthy outcomes" pay model for Medicare, as opposed to a "Fee-For-Service" pay model for Medicare Advantage.
In a "healthy outcomes" model they are paid for how healthy they are actually keeping people. On a "Fee-For-Service" model, they are paid for any and all individual services they can run up.
They are pissed that they can't keep running up hospital bills for all kinds of crap...much of it not necessary.
32 systems are also a drop in the bucket of total available systems. They're just blowing it up to try and make it seem like a huge thing. Hospital systems are always coming and going on any and all plans.
They hate Medicare Advantage plans because they can't run up peoples bills and there's monetary oversight.
Just Google "doctors nurses medicare fraud" and then click on "news" for a real eye-opener.
Hospitals are not some super benevolent charity organizations that just "really care about the people." They are no different than cutthroat Wall Street with entire boards of directors that LOVE money.
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just-a-client
Expert
- 41
1. Upcode everyone. Get more $ monthly from Medicare to care for these "sick" patients. (Example: someone had a heart attack 3 years ago, and is fine now. Diagnosis codes are supposed to be for current encounters and active conditions only, but they keep submitting the codes for resolved problems.)
2. Naturally, you spend less on that person than Medicare's risk model projected. The plan kept the person out of the hospital, and was not just paid more monthly for caring for that person (the extra payments assumed extra costs would be incurred), but gets bonuses for keeping them healthier than expected, which also raises their star ratings which gets them even more bonuses.
In that scenario, the thing that is the most healthy is the balance sheet. The members might also be healthy, but that was not necessarily thanks to anything the plan is actually currently doing.
InsuranceGuy29
Guru
- 803
The plans focus on prevention and aggressive preventative outreach. You don't need metrics to even measure this.....just simple common sense. Someone goes on original Medicare and that's it.
They hear from no one, and they are just out on their own to navigate their own healthcare. Problem is, most people are not good at managing their own healthcare. You'd be shocked at the amount of people that ask me, a health INSURANCE agent, for health advice.
Obviously something I'm not qualified to be giving at all. Managed care makes sure they are regularly getting preventative testing, preventative treatments, and deploys early prevention and care techniques. Original Medicare does not.
And as far as upcoding, that was a very small problem with some employees. There are always a small amount of bad actors in every job and area of life. That will never change.
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