Growth in Medicare Advantage Surprises Even Experts

March 12, 2018 ABILITY

With so much turmoil in healthcare these days, Medicare Advantage (MA) is proving a bright spot for payers and patients, although many healthcare organizations have administrative headaches in working with these plans. MA plans are here to stay – the number of plans has grown by 14 percent in 2018 over the previous year!

MA plans are thriving, thanks to the steady stream of baby boomers aging into Medicare at a rate of 10,000 a day. Beneficiaries are attracted to MA plans because the premiums are much lower than with traditional Medicare, with some payers even offering no-premium options.

Incentives Shaping Plan Growth

Industry experts predicted payers would lose interest in MA as the Centers for Medicare and Medicaid Services (CMS) gradually tapered reimbursement down to match traditional Medicare rates. Payers still find that MA plans make financial sense, however, in part because little marketing needs to be done to members once they enroll, saving payers money. Few beneficiaries change plans year to year. Plan members are the first to say they stay where they are because of the overwhelming number of plan choices available every fall.

Despite administrative issues, MA plans can help providers renew their focus and experience greater satisfaction with their mission to deliver thorough, preventive, coordinated care. Under MA, providers are incentivized to build long-term relationships with patients, to care for both healthy and sick patients, and to have the expanded view of a patient’s health picture that results in better care and outcomes.

So what do providers need to know if they want to see MA patients?

They will contend with complexity. Healthcare organizations will need to tackle the administrative complexity associated with MA payer requirements for pre-authorizations and referrals, especially for patients in HMO-style plans. More attention to patient eligibility is needed as more plans enter the market. Home health agencies and other areas previously dominated by the uniform rules of traditional Medicare now find they have new plan models and rules to contend with that aren’t clearly explained.

Correct coding and billing are essential. Healthcare organizations need to follow plan requirements for pre-authorizations, referrals, coding and billing when they act as the “medical home” for MA members in HMO-style plans. CMS recognizes chronic care and overall care coordination as part of good care, but plans handle these differently, so it’s critical to know the rules and to code and bill accordingly.

Understand patient/provider financial risk. MA brings more financial risk to patients and therefore to providers and healthcare organizations. While patients may enjoy low premiums, they may be a little unrealistic about the cost-sharing that will come when they actually need care. If patients are surprised by deductibles and coinsurance, it may become challenging for providers to collect that revenue. Having multiple payment options for patients, including at the front desk and online is a must. (For a look at how to expand these choices, click here. [sbp link])

Expect patients who expect technology. The trailing edge of boomers (born between 1956 and 1964) is different from the leading edge of the boomer cohort providers already know. Younger boomers are already familiar with managed care and various plan designs and depend on technology to run big parts of their lives. Trailing boomers expect providers and healthcare organizations to be tech-friendly when it comes to portals, appointment reminders and payment options.

Help create more accurate directories. CMS said recently it will crack down on inaccurate MA provider directories, which have long frustrated beneficiaries and providers. (CMS research shows that nearly half of MA directories are inaccurate.) While provider directories are primarily the responsibility of payers, some offer portals where providers can update their information. Keeping up with this ultimately reduces administrative hassles and confusion for administrative staff. (For other tips on working with provider directories, read our flipbook.)

Catch the Medicare Advantage Wave

Healthcare organizations have every reason to accept and understand MA plans, as another 26 million baby boomers will age into Medicare between now and 2030. Having the right information and tools to thrive with these popular plans is just smart practice in 2018 and beyond.

For a snapshot of the Medicare Advantage market in 2018, view our infographic.


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