Hospitals are the Patient Advocate
Hospital and Provider Education
Providers and other hospital leaders recognize that every patient has unique needs. Here is a deeper dive into some relevant information as you consider what is right for your hospital, your practice and your hospital and patients.
The High-Level Points
- Original Medicare and hospital-based Medicare Advantage Plans allow patients to continue visiting their trusted hospitals and hospital-based providers.
- Original Medicare with a supplement may be a better choice for seniors with chronic conditions, frequent hospital stays, rehabilitation or long-term care needs.
- Medicare Advantage plans may be a better choice for seniors who are relatively healthy and embrace wellness activities.
- Many hospitals across the nation are choosing not to accept certain Medicare Advantage plans, due to their high number of delays, denials or postponement of care.
Pro Tip: Remember that regardless of whether the patient with Medicare Advantage is in network or out of network at your hospital, prior authorization will be required for non-emergency health services and coverage could be denied.
By The Numbers
Payers who own Medicare Advantage plans aggressively market these plans directly to those eligible for Medicare, especially during open enrollment time. As a result, more individuals are choosing Medicare Advantage over Original Medicare compared to 10 years ago. While premiums may be lower and the “bundled” nature of Medicare Advantage plans may seem attractive, the complex nature of Medicare Advantage plans is driving up the cost of healthcare and many patients are faced with suddenly becoming out-of-network or having excessive out-of-pocket costs with Medicare Advantage plans.
Share of Beneficiaries Enrolled in Medicare Advantage
Note: Includes only Medicare beneficiaries with Part A and B coverage.
Medicare Advantage Enrollment continues to grow with 32.8 million beneficiaries in 2024.
The Denial Debacle
Major healthcare payers face congressional inquiries and federal court lawsuits regarding questionable denial practices. Medicare Advantage plans’ denial rates have continued to increase, reaching 55.7% in the first two quarters of 2023. Oklahoma health systems spend valuable time and resources combatting denials and delays and managing pre-authorization requirements of Medicare Advantage. A recent survey by the American Medical Association found physicians and their staff average about 14 hours a week just completing prior authorization requests. (AHA, 2023)
Prior Authorization Denial Rates
More than 80% of denied prior authorization requests that were appealed were overturned. All Medicare Advantage insurers require prior authorization for some services, all plans have their differences. This means more work for hospitals to ensure they submit reimbursement paperwork correctly. (Jeannie Fuglesten Biniek, 2024)
Source: (AHA, 2023)
Medicare Open Enrollment Season runs Oct. 15 – Dec. 7, 2024
Now is the time to make sure you’re choosing the best Medicare option for you in 2025.
For more information visit Medicare.gov