Medicare Advantage Plans and Doctors

Happy elderly patient meeting with doctor to discuss the good and bad of Medicare Advantage.

We’ve heard both sides of the Medicare Advantage (Part C) argument. There is no right or wrong answer when it comes to Medicare Advantage plans – the right answer for you may be different than the right answer for your friend, as almost anything Medicare-related. It all depends on your unique set of circumstances. But how do doctors feel about Medicare Advantage plans? Their voices are not ones we have heard much about so far. Do they find them beneficial to the financial success of their practices, or do they find it harder to stay afloat because they are accepting lower fees? Do Medicare Advantage plans interfere too much with treatment?

Let’s discuss a few of the problems providers have witnessed when treating Medicare Advantage plan members.

Increased Financial Burden

A premium-free plan sounds great, doesn’t it? But like all things in life, if it sounds too good to be true, it probably is. The truth is, if you are seeking care often, your copayments could quickly add up to much more than a plan that has a higher premium but no copayments.

Doctors who have patients that come in regularly see this all the time. If you are healthy and rarely have an office visit, that $25 copayment is not a big deal. But what if you are going to the doctor weekly or even more often? What about the other copayments associated with these plans?

Every Medicare Advantage plan is different, but these copayments are an example of one of the plans we looked at:

  • Hospital stay: $175/day
  • Ambulance transportation: $300
  • Radiology: $125
  • Lab tests: $100
  • Diabetic supplies: 20%

If you compare those copayments to what you would pay with a Medicare supplement, you will find that you end up paying much more than you would have for a plan that didn’t boast a $0 premium.

Unstable Medicare Advantage Insurance Carriers

A Medicare Advantage plan can cease to exist at any time. Of course, you’ll be able to enroll in a new plan, but what if you have treatment that needs to happen immediately? Be aware that, for example, in Florida in 2014 there was a plan that was popular and that declared insolvency. Overnight, doctors canceled hundreds of appointments for patients with this plan.

Concerned senior doing research on Medicare Advantage.
Patients with a long history of illness could have their treatment disrupted or even changed with a new provider.

Disruption in the Continuity of Care

Just like plans can quickly disappear, they can also terminate their contracts with providers – or vice versa. The insurance company does not even have to state a cause in terminating the relationship. Since most Medicare Advantage plans require their members to see providers in a specific network, this leaves patients without a primary care physician.

There will be other providers in the plan’s network, but switching doctors, especially if it happens often, disrupts the continuity of care for patients. Patients with a long history of illness could have their treatment disrupted or even changed with a new provider.

Too Many Rules for Adequate Treatment

Many Medicare Advantage plans require their members to obtain a referral from their primary care physician prior to seeing a specialist. That requirement is probably the simplest rule for members to follow, though it does mean that the member has to pay their copay twice instead of just one time at the specialist’s office.

There are a host of other rules in Medicare Advantage plans. Insurance companies may require prior authorization before treatment, and they may even require that the provider try other treatments before the one they had recommended. Who has the medical license in this scenario?

Failing to follow the rules often means that services are simply not covered by the insurance company.

The Benefits are Less than Promised

Watch any Medicare Advantage commercial on TV, and you will notice the advertiser is promising you everything. Free hearing aids, glasses, and all the dental work you could possibly need! However, when the patient enters the clinic, they find out that those benefits are not quite what they signed up for.

We don’t mean to say that your insurance carrier lied about the plan. We just know that there is a lot of fine print you’ll need to read before rejoicing about all the extra benefits.

Other Considerations

There are a few other issues with Medicare Advantage plans that some doctors have witnessed.

Some patients have problems getting emergency care due to rationing. Advantage plans that include prescription drug benefits (Part D) may even have rations on more expensive medications.

Of course, you will be restricted to a certain network of doctors and providers. This is yet another form of rationing that works well for the insurance carrier but limits the choices that plan members have.

Lastly, receiving care while traveling is nearly impossible unless the member wants to pay out-of-pocket for all the services. Instead, they may choose to postpone care, which could exacerbate the condition and require more extensive treatment later.

We’re still not saying Medicare Advantage plans are always bad. For healthy individuals who live in areas with great access to care, they can absolutely be a great option that saves them money on their premiums. The problems begin when individuals get sick and need more care.

If you are considering an Advantage plan, make sure you understand the copays associated and talk with your agent about other healthcare options. We can compare each type of plan and make sure you choose the one that is going to give you the most coverage.

Website | + posts
Call & Get Help Skip to content