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The annual enrollment period for Medicare Advantage plans ended last week, which means the torrent of mailings that has flooded my mailbox over the past few months will likely slow to a trickle (some of these insurers never give up). It also means some 30 million seniors will have chosen a plan at a time when the relationship between healthcare providers and the insurance companies that pay them for their services has never been more tenuous.

As Julie Appleby reports in KFF Health News, issues involving reimbursement rates, pre-approval requirements, and claim denials have forced hospital systems and medical groups across the country to cut ties with several major Medicare Advantage insurers in recent months, leaving plan members scurrying to locate providers that will accept their suddenly rejected insurance.

In San Diego, for instance, more than 30,000 seniors were forced to find new doctors after two major Scripps Health medical groups announced they would no longer accept patients covered by Medicare. Nebraska seniors have also been searching for new healthcare options after nearly a third of all hospitals in their state cut ties with Advantage plans.

Meanwhile, in Louisville, Ky., a Baptist Health medical group, including its 1,500 physicians and other practitioners, canceled their Medicare contract with Humana in September; nine hospitals in the system are threatening to end similar deals with UnitedHealthcare and Wellcare Health Plans in January unless they can negotiate a more favorable contract. And Southeast Georgia Health System, with its two hospitals, two nursing homes, and physician network in Brunswick, Ga., is poised this month to end its relationship with Wellcare Medicare Advantage.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” Chip Kahn, MPH, president and CEO of the Federation of American Hospitals, tells Appleby.

Some of these actions can be chalked up to negotiation posturing, but David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy, says “this feels different” from typical contract wrangling. Healthcare providers are “much more vocal” these days about what they see as unfair practices by insurers.

And Don Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, argues that the concentration of a few major players in the insurance field — UnitedHealthcare and Humana insure about half of all Medicare Advantage beneficiaries — may be sparking the uprising.

“There have been serious problems with payment suspensions and reviews that annoy the providers,” he explains. “I would not be surprised if we start to see more of this pushback” as a handful of insurance companies continue to dominate the industry.

Insurers, for their part, argue that they are simply trying to protect their Advantage members. In a letter to the Centers for Medicare and Medicaid Services (CMS) in February, their lobbying firm, America’s Health Insurance Plans, contended that the oversight insurers are practicing prevents “inappropriate care by catching unsafe or low-value care, or care not consistent with the latest clinical evidence.”

But a report released last year by the U.S. Health and Human Services Department’s inspector general found that nearly one in five claims insurers rejected during a randomly sampled period in 2019 involved care that was covered under Medicare guidelines. More recently, the Biden Administration addressed this — and other Advantage plan issues — by drafting a rule, scheduled to take effect in January, that would require these plans to offer “the same medically necessary care” as the traditional Medicare program.

The inspector general’s report, Lipschutz notes, may have spurred the recent cancellations by hospitals and physician groups. Whether those findings — or the new guidelines — will have much effect on the way insurers do business, however, is anyone’s guess. American Hospital Association officials have their doubts. The trade group alerted CMS in October that its members “have heard from some [insurers] that they either do not plan to make any changes to their protocols” or “have made changes to their denial letter terminology in a way that appears to circumvent the intent of the new rules.”

So, we’re likely to see more providers cut ties with these insurance companies in the months ahead, which will force increasing numbers of seniors to pursue other healthcare options. And as anyone who has spent any time trying to navigate the jumbled Medicare Advantage marketplace can tell you, switching plans — and doctors — requires a lot more effort than sifting through all that junk mail in search of a decent offer.

Craig Cox
Craig Cox

Craig Cox is an Experience Life deputy editor who explores the joys and challenges of healthy aging.

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