Medicare Advantage Plans have grown in popularity over the years and now enroll over 30 million Medicare beneficiaries. However, among healthcare providers, Medicare Advantage often draws criticism and frustration compared to Original Medicare.
There are a variety of reasons why many doctors do not like accepting or working with Medicare Advantage Plans. Understanding their gripes can help beneficiaries make the right Medicare choices for their personal situations.
What is Medicare Advantage?
Medicare Advantage, also known as Medicare Part C, refers to private health plans that contract with Medicare to provide all Part A and Part B benefits. Medicare Advantage Plans include:
- HMOs (Health Maintenance Organizations)
- PPOs (Preferred Provider Organizations)
- PFFS (Private Fee-for-Service)
- Special Needs Plans
In addition to covering all Part A and Part B services, many Medicare Advantage Plans offer extra benefits like prescription drug coverage, dental, vision, and more.
Medicare pays the private insurers a set monthly amount per enrollee. In turn, the insurer agrees to cover healthcare costs for members. Medicare Advantage Plans aim to provide the same coverage as Original Medicare but often at a lower premium cost.
However, to control expenses, Medicare Advantage insurers also implement more restrictions on care access and providers compared to Original Medicare. This is where much doctor dissatisfaction with Medicare Advantage stems from.
Doctors Dislike Medicare Advantage Prior Authorization Requirements
One of the top grievances doctors have with Medicare Advantage Plans is needing to obtain prior authorization for many services, treatments, tests, and prescriptions.
Under Original Medicare, physicians can order medically necessary care and medications for patients without delays for approvals. But with Medicare Advantage Plans, doctors must submit requests and wait to hear back regarding whether proposed treatments will be covered.
The prior authorization process requires extensive paperwork and phone calls. Doctors find it burdensome and say it slows down care. Further frustration comes when Medicare Advantage Plans deny or alter physician-recommended care plans in favor of less costly alternatives.
Doctors feel prior authorizations undermine their expertise and ability to make the best clinical decisions for patients. Their medical judgement and patient preferences take a backseat to Medicare Advantage cost containment protocols.
Limited Network Providers Hamper Referrals
Another common gripe doctors have with Medicare Advantage is limited provider networks. While Advantage networks have expanded in recent years, many plans still only cover care from selected doctors and facilities in a geographic area.
For physicians, narrow Medicare Advantage networks prevent them from referring patients to the specialists they believe are most qualified or appropriate. They dislike having their hands tied regarding where to send patients for optimal care management.
PPO plans offer out-of-network coverage but at higher patient cost sharing. HMOs tend to have the smallest networks, requiring referrals to in-network providers only except in emergencies. Doctors find limited choices unavoidably lower the quality of care coordination they can provide.
High Cost Sharing Leads to Surprise Medical Bills
In general, Medicare Advantage Plans have lower premiums but much higher cost sharing amounts compared to Original Medicare. Doctors say copays, deductibles, and coinsurance often leave patients with “surprise” medical bills.
For example, a hospital stay might cost $1,500 out-of-pocket under Medicare Advantage versus only $400 under Original Medicare. Doctors know seniors frequently cannot afford Advantage plans’ high cost sharing. This sticks providers with unpaid debts when patients lack resources to cover their portion of treatment costs.
Conversely, Original Medicare combined with supplemental insurance like Medigap covers almost all out-of-pocket amounts, providing financial protection for beneficiaries and predictability for doctors. But such extensive coverage is lacking in Medicare Advantage for many.
Advantage Members Have Access Gaps Returning to Original Medicare
Doctors also get frustrated when Medicare Advantage patients want to switch back to Original Medicare to avoid plan drawbacks but then cannot get the coverage they need.
For example, Medigap enrollment is only guaranteed within six months of enrolling in Part B. After that, applicants can be denied or charged more based on health status. So former Advantage members may struggle to find affordable Medigap Plans.
The same applies for Part D prescription coverage. Enrollment is time-limited or pre-existing conditions can impact eligibility. So doctors see patients stuck with coverage they no longer want due to rules preventing them from returning to more desirable Original Medicare benefits.
Tips for Evaluating Medicare Advantage vs. Original Medicare
Doctors prefer Original Medicare overall for its clinical flexibility and predictable coverage terms. But each Medicare beneficiary’s needs and priorities differ. Consider the following when deciding between Medicare Advantage and Original Medicare:
- How does your health compare to the “average” senior? If you have multiple chronic conditions and take several medications, Original Medicare plus Medigap may suit your frequent healthcare needs better.
- Are there doctors or specialists you want to keep seeing? Check if they accept both Medicare Advantage plans and Original Medicare before choosing coverage.
- How do out-of-pocket costs compare? Even with lower Medicare Advantage premiums, copays and coinsurance may drive up total yearly costs if health issues develop. Run estimates for both options.
- How important is dental or vision coverage? Advantage plans often include extra perks that aren’t part of basic Original Medicare.
- How often do you travel out of town? Original Medicare works nationwide, while Medicare Advantage networks are regional.
As evidenced by doctors’ common complaints, Medicare Advantage does involve tradeoffs compared to Original Medicare’s flexibility. But the right individual factors like budget and health status can make it a satisfactory choice for some beneficiaries.
Why Do Doctors Prefer to Work with Original Medicare?
Now that you understand some of doctors’ frustrations with Medicare Advantage Plans, it becomes clearer why most prefer working with Original Medicare. Here are some of the key advantages they see with Original Medicare:
- No prior authorizations required – Doctors can order tests, therapies, procedures, hospitalizations, medications, and supplies for Medicare patients however they see fit for the patient’s condition without waiting for insurance approval.
- Minimal claim rejections – Original Medicare rarely denies coverage for services it defines as medically necessary, unlike Advantage plans that may refuse payment after the fact for services they decide unneeded. This provides financial confidence for doctors.
- Charges limited to Medicare-approved amounts – Providers know exactly how much they will be paid by Medicare for each service versus Advantage plans that may negotiate separate rates paying doctors less.
- No limited networks – Physicians can send patients anywhere for care, allowing better collaboration between health professionals. Over 90% of doctors accept Original Medicare compared to the smaller provider networks of Advantage plans.
- Lower patient cost sharing – Supplemental insurance like Medigap fills almost all Original Medicare’s out-of-pocket gaps so doctors don’t have to worry about patients facing unaffordable bills for covered services.
In short, doctors believe Original Medicare with supplemental coverage provides the best balance between appropriate care access and cost management. Dealing with Medicare Advantage restrictions seems only to benefit insurers over patients and providers in many circumstances.
Disadvantages of Medicare Advantage Plans from Doctors’ Perspectives
Understanding why doctors overwhelmingly favor Original Medicare also highlights what they see as the biggest disadvantages of Medicare Advantage Plans:
Prior authorization requirements – Delays care, discourages thorough treatment, and dismisses doctors’ judgment.
Limited networks – Reduces provider choices and care coordination options.
High patient cost sharing – Leads to unaffordable healthcare bills even for crucial services.
No out-of-network coverage – Restricts care access when traveling or needing distant specialty treatment.
Changing benefits yearly – Insurers can alter Advantage coverage from year to year, disrupting care plans.
Profits over patients – Insurers answer to stockholders over beneficiaries or doctors, influencing coverage decisions.
Limited Medigap access – Difficult to enroll in Medigap after being in Medicare Advantage due to health screening.
From their viewpoint, doctors see more barriers than benefits to providing quality care under Medicare Advantage rules. But each senior’s mileage may vary based on individual healthcare priorities and needs.
Critical Points to Consider about Medicare Advantage Plans
If you do opt for a Medicare Advantage Plan, discussing the following concerns with your doctors can help improve the experience:
- Ask which specialists they recommend most often for referrals and find out if they are in your plan’s network.
- Confirm the hospitals where they have admitting privileges and if those facilities are covered by your plan.
- Inquire about the prior authorization requirements of the plan and procedures for requesting approvals.
- See if any of your prescription medications require pre-approvals or have quantity limits under the plan’s formulary.
- Ask whether your plan has even denied a request from them in the past for a test, procedure, or medication they thought was needed.
Proactively communicating with doctors helps set expectations around Medicare Advantage limitations. Doctors also suggest having a backup plan whether that’s maintaining coverage under a secondary insurance policy or having savings to cover significant out-of-pocket medical costs that might arise.
Key Takeaways on Doctors’ Discontent with Medicare Advantage
In summary, most physicians express clear preference for working with Original Medicare over Medicare Advantage Plans for reasons including:
- Dislike of prior authorization protocols that disrupt care decisions
- Limited provider networks that restrict referrals and choice
- High out-of-pocket costs that negatively impact patients
- Hassles and delays getting claims paid by Medicare Advantage Plans
- Inability to provide the best possible care under plan restrictions
But whether advantages of Original Medicare outweigh lower Medicare Advantage premiums depends on each beneficiary’s finances, health status, and specific needs.
Understanding doctors’ criticisms of Medicare Advantage can help you make a coverage decision aligned with your doctors’ recommendations. But don’t assume Original Medicare is automatically better even if your physician voices displeasure with Advantage plan obstacles. Make sure to discuss concerns directly with your doctor and weigh all pros and cons for your situation.
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Why do doctors not like Medicare Advantage plans?
Doctors may not like Medicare Advantage Plans because they often have a limited network of doctors that they can work with. These plans may require doctors to accept Medicare Advantage Plan rates, which are typically lower than traditional Medicare rates.
What are the pros and cons of Medicare Advantage Plans?
The pros of Medicare Advantage Plans include potentially lower out-of-pocket costs, additional benefits not covered by traditional Medicare, and the convenience of having one plan that covers both medical and prescription drug coverage. The cons of Medicare Advantage Plans include limited provider networks, increased cost-sharing for certain services, and the need to get referrals for specialists. It’s important for individuals to carefully consider their healthcare needs and preferences before selecting a Medicare Advantage Plan.
Do many doctors not like Medicare Advantage Plans?
While not all doctors have an issue with Medicare Advantage Plans, there are some doctors who may prefer to work with traditional Medicare coverage. This could be due to reasons such as restricted networks, lower reimbursement rates, and more administrative burdens associated with Medicare Advantage Plans compared to traditional Medicare.
Do many Medicare Advantage Plans require a network of doctors?
Yes, many Medicare Advantage Plans may offer or have a network of doctors that participants must use to receive the full benefits of the plan. Using out-of-network doctors may result in higher out-of-pocket costs or no coverage at all. It’s important for individuals considering Medicare Advantage Plans to review the provider network to ensure their preferred doctors are included.
Why do doctors not like many Medicare Advantage Plans?
Some doctors may not like many Medicare Advantage Plans due to reasons such as restricted networks, lower reimbursement rates, and more administrative burdens compared to traditional Medicare.
Do many Medicare Advantage Plans require participants to enroll in a Medicare Supplement?
No, Medicare Advantage Plans do not require participants to enroll in a Medicare Supplement. Medicare Advantage Plans are an alternative to Original Medicare and typically include all the coverage found in Medicare Parts A and B, plus additional benefits.re Advantage Plans?
The cons of Medicare Advantage Plans include limitations on providers, potential higher cost-sharing for certain services, and the need for referrals to see specialists.
Can Medicare Advantage Plans require participants to choose a Medicare Advantage Plan in their area?
Medicare Advantage Plans often have specific service areas or regions where they operate. Participants must reside within the plan’s service area to be eligible for enrollment. It’s important to check the availability of Medicare Advantage Plans in your area before making a decision.
Can Medicare Advantage Plans require participants to enroll in Medicare Part B?
Enroll in a Medicare Advantage Plan and asking this? Yes, in order to be eligible for Medicare Advantage Plan, participants must be enrolled in Medicare Part A and Part B. Medicare Part A covers hospital insurance, and Part B covers medical insurance. Medicare Advantage Plans may work alongside Medicare Parts A and B to provide additional benefits and coverage.
Can doctors refuse to accept Medicare Advantage insurance?
Doctors have the option to accept or refuse Medicare Advantage health insurance. Some doctors may choose not to participate in Medicare Advantage Plans due to reasons such as restricted networks, lower reimbursement rates, and more administrative burdens compared to traditional Medicare. However, many doctors do accept Medicare Advantage insurance and work with these plans to provide healthcare services to their patients.