Should I accept Medicare Advantage?
As the number of beneficiaries with Medicare Advantage coverage continues to increase, you’re probably asking yourself this question: ‘Should I accept Medicare Advantage?’ If you only look at ever-increasing enrollment numbers, you may be inclined to say yes. However, a deeper dive into the experiences of Medicare Advantage network providers in your area might make you think twice. For example, many providers continue to struggle with prior authorization requirements and claim denials, some of which experts say are intentional.
Should doctors accept Medicare Advantage? It’s not an easy or straightforward decision. Doctors not accepting Medicare Advantage could create access challenges for patients who need their services. On the other hand, Medicare Advantage network providers might need to devote extra revenue cycle management resources to getting paid.
Not sure whether you should become one of many Medicare Advantage network providers? Here are six questions to help you decide whether participation with Medicare Advantage makes sense for your medical practice.
1. How many of your patients are covered through a Medicare Advantage plan? This may seem like an obvious question, and it’s because it is. If you don’t see many patients with Medicare Advantage coverage, it may not make sense to go in network. However, keep in mind that your patient population and its coverage could fluctuate over time, meaning you may need to revisit the decision in the future. For example, during Medicare’s annual open enrollment period, you may see changes in your patients’ coverage. This is a great time to ask yourself: ‘Should I take Medicare Advantage?’
2. What is the Medicare Advantage plan’s Star Rating? The Medicare Advantage Star Rating is a score that Medicare assigns to each Medicare Advantage plan based on how well the plan manages chronic conditions, how well it handles member complaint reports, the process it uses to make decisions regarding appeals, and other factors. If the Medicare Advantage plan you’re considering performs poorly (i.e., it has a one-star rating for ‘poor’ or two-star rating for ‘below average,’ you may want to think carefully about going in network.
3. Do you have enough revenue cycle management staff to handle potential denials? In 2021, more than 35 million requests for prior approval were submitted for Medicare Advantage enrollees, and more than 2 million of them were denied. If you decide to go in network, you may need to focus your efforts in this area or work with an outsource revenue cycle management partner to streamline prior authorizations and ensure revenue integrity.
4. How many other physicians in your area accept Medicare Advantage? One recent study found that physicians who treat patients with greater social risks are less likely to be included in Medicare Advantage networks. Authors of the study say there could be many reasons for this, one of which is that physicians may forego becoming a Medicare Advantage network provider when traditional Medicare pays more. However, if there’s a large number of doctors not accepting Medicare Advantage in your area (and you do accept it), your in-network status could help you gain a competitive edge and attract more patients to your medical practice.
5. Does the Medicare Advantage plan cover your high-volume services? Every Medicare Advantage plan is different, and before deciding whether to go in network, you’ll want to ensure the plan covers the services you perform most frequently. Otherwise, patients would need to pay out of pocket, and that could usher in a whole host of patient collection challenges.
6. How well-versed are you in risk adjusted coding and clinical documentation? Medicare Advantage plans receive a capitated payment from Medicare based on each beneficiary’s health risks and costs as reflected by coded data. This means that to ensure accurate risk-adjusted payments to your medical practice, you’ll need to capture the patient’s severity of illness and risk of mortality through clinical documentation and coded data. This may require additional training for physicians and medical coding staff.
Looking ahead
Should doctors accept Medicare Advantage? The answer will vary depending on the medical practice. While there are many doctors not accepting Medicare Advantage, there are plenty who do. Should I accept Medicare Advantage? Medicare Advantage network providers need to weigh the pros and cons and promote accurate and complete medical coding to ensure revenue integrity. Learn how edgeMED can help.
