As the demand for Medicare Advantage plans continues to rise, health systems are facing increased challenges in relation to delayed and denied coverage. This has resulted in some systems opting out of contracts with private plans. In fact, Medicare Advantage denials rose nearly 56% for the average hospital from January 2022 to July 2023, according to a joint report by the American Hospital Association and Sintellis. The data also showed that denials and inconsistent reimbursement led to a decline in the number of hospitals’ cash reserves by 28%.

Despite these challenges, Medicare Advantage enrollment is on the rise, and insurers see an opportunity as more people become eligible for Medicare. According to KFF, Medicare Advantage enrollment increased by 8%, or 2.3 million beneficiaries, last year. However, some health systems find it difficult to work with Medicare Advantage plans that refuse care in order to increase their profits. This has led UNC Health and other systems to develop partnerships with more reliable payers and potentially reduce Medicare Advantage plans that are not good partners.

Will Bryant, CFO of UNC Health, explained during a panel at Becker’s 11th CEO+CFO Roundtable that health systems need better communication and partnerships with payers to develop mutually beneficial solutions without interfering with CMS or others. He expressed hope that future partnerships between payers and providers will help solve problems that have arisen over the past 30-plus years.

In response to these challenges, CMS is proposing more regulations to address this issue. This includes banning volume-based bonuses to third-party marketing organizations and requiring health plans to provide mid-year notice to enrollees of any fringe benefit changes enacted. We hope that these regulations will lead to better partnerships and communication between health systems and Medicare Advantage plans

By Editor

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