What challenges might physicians experience when treating patients in a Medicare Advantage plan?
“The plan itself has control over what it will pay for and they’re much more aggressive about it than traditional Medicare,” Dr. Candler said. Medicare Advantage plans are often structured as health maintenance organizations, with narrow provider networks and extensive prior authorization requirements.
Dr. Candler gave an example of a plan that offers transportation to medical appointments – a seemingly great benefit. But what if someone needs to see a cardiologist and the only cardiologist within the plan is 100 miles away? That’s too far for the transportation benefit, it turns out.
Or a Medicare Advantage plan requires a physician to first do a physical exam before ordering an MRI, even though in the physician’s judgment only the MRI will have diagnostic value. Or the plan denies coverage for a service that’s already occurred. These practices aim to weed out unnecessary care but at the cost of patient confusion or physician time in arguing why something should be covered.
“The argument from us as physicians would be, ‘Just trust us to practice good medicine,’” Dr. Candler said.
Beside these concerns at the physician level, the regulations surrounding Medicare Advantage plans may open the door to billing fraud.
How do Medicare Advantage Plans interact with diagnosis codes?
“I just can’t stand when I see fraud in the health care system,” said Nancy Keating, MD, MPH, an internist at Brigham and Women’s Hospital and a health policy professor at Harvard Medical School, both in Boston.
This July, Dr. Keating published a report in the Annals of Internal Medicine about a patient of hers whose health insurer – a Medicare Advantage plan – claimed had diabetes with comorbidities and was morbidly obese. None of this was true. But submitting such diagnoses to CMS would suggest that Dr. Keating’s patient was especially ill, leading to greater reimbursements from CMS for covering her care.
“I’m not averse to paying plans that are taking care of sicker patients more, but we need to figure out who those patients truly are,” Dr. Keating said.
“It is absolutely true and widely proven that Medicare Advantage plans do a lot of clever things” to inflate diagnoses, added Dr. Ankuda. Also, she said that Medicare Advantage plan representatives would say this is legitimate work, as the entire point of Medicare Advantage is to pay more for caring for sicker patients.
“I don’t think anyone here is acting in bad faith. It’s just that [there are] very different incentives,” Dr. Ankuda said.
How can Medicare Advantage be improved?
Dr. Keating believes that CMS should reduce the number of diagnosis codes allowed within Medicare Advantage to thwart the potential for upcoding. Dr. Ankuda thinks the biggest problem is that there is no good way for patients to choose among Medicare Advantage plans.
“I don’t see it as Medicare Advantage is bad or Medicare Advantage is good. MA plans are incredibly diverse,” Dr. Ankuda said. The problem is that it’s very hard for patients to tell which plans are delivering the best care, what their out-of-pocket costs will actually be, or how often a plan denies payment.
Dr. Ankuda argues for much more data transparency around such plan factors.
Dr. Candler and Dr. Ankuda had no relevant conflicts. Dr. Keating is a consultant to the Research Triangle Institute, which advises CMS about Medicare Advantage billing codes.