List of Hospital Systems dropping MA for 2025

[Millwood]

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

www.beckershospitalreview.com

 

[somarco]

Anthem/BX, Humana, UHC, Aetna . . . kicking out the big boys.

BAM!

 

[Fisher]

Scripps ain't even playin'! Modeling the Phoenix Mayo playbook.

 

[InsuranceGuy29]

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

www.beckershospitalreview.com

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.

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.

 

[just-a-client]

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.

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.

 

[somarco]

I doubt CMS has the manpower/computer power, to audit things like upcoding for everyone.

My impression is that audits rarely, if ever, occur on a mass basis absent a whistleblower.

 

[InsuranceGuy29]

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.

The plans focus on prevention and aggressive preventative outreach. You don't need metrics to even measure this.....just simple deductive reasoning. 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.

I'm very physically fit, and very into supplements and keeping healthy, so I probably give off that vibe, but still. Many people are genuinely lost on how to go about staying healthy.

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 at a few of the companies. There are always a small amount of bad actors in every job and area of life. That will never change.

 

[somarco]

Don't you just love it when someone who has no clue about how health care and insurance actually works crashes a thread with insane theories but without any documentation to support their argument?

 

[InsuranceGuy29]

Don't you just love it when someone who has no clue about how health care and insurance actually works crashes a thread with insane theories but without any documentation to support their argument?

Don't you just love it when people are cowardly and don't address someone directly in quotes? Somarco, you don't need documentation for common sense. Forgive me for having a functioning brain.

 

[renee15]

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.

You are correct. All those assessments to find problems led to more for carriers and Medicare caught on. Loss ratios increasing led to denial of coverage