Medicare Advantage

Primary care delivery is similar across all Medicare patient mixes

March 27, 2024 - Care delivery, care coordination, and administrative challenges were similar across primary care physicians serving traditional Medicare patients and those serving Medicare Advantage patients, a Commonwealth Fund brief found. Unlike traditional Medicare, Medicare Advantage plans receive capitated payments from the government to cover...

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Private payers initially deny nearly 15% of medical claims

by Jacqueline LaPointe

It may take some time to get paid for medical services, suggests a new survey of hospitals, health systems and post-acute care providers. Nearly 15 percent of medical claims submitted to private...

Medicare Advantage Denials Jump 56%, Commercial Denials 20%

by Jacqueline LaPointe

Hospitals and health systems have seen a significant spike in claim denials as Medicare Advantage and commercial payers deny more of their reimbursement. A new analysis of data from over 1,300...

More Provider Orgs Have Value-Based Contracts With Private Payers

by Victoria Bailey

More provider organizations are participating in value-based contracts outside Medicare, as three-quarters of respondents were under contracts with commercial and Medicare Advantage plans in 2022, a...

MGMA: Medicare Advantage Growth Exacerbates Prior Authorization Burdens

by Victoria Bailey

As Medicare Advantage enrollment grows, medical practices are experiencing more prior authorization burdens, including higher administration costs and disrupted workflows, a report from the Medical...

AMGA Opposes Proposed Medicare Advantage Coding Changes

by Victoria Bailey

AMGA has asked CMS not to finalize the coding changes included in the 2024 Medicare Advantage Advance Notice that would revise diagnoses and condition categories in the hierarchical condition...

AMA Urges CMS to Finalize Medicare Advantage Prior Authorization Reforms

by Victoria Bailey

The American Medical Association (AMA) and 118 other medical organizations have urged CMS to finalize its proposed prior authorization reforms for the Medicare Advantage program. In a letter to CMS...

MGMA Calls for Prior Authorization Reform in Medicare Advantage

by Victoria Bailey

The Medical Group Management Association (MGMA) has urged CMS to implement policies that support prior authorization reform and value-based care contracts within the Medicare Advantage program. MGMA...

When Cutting Healthcare Spending, MA Pulls Ahead of Medicare ACOs

by Jacqueline LaPointe

Average spending on Medicare beneficiaries enrolled in Medicare Advantage (MA) plans was much lower compared to the same metric of spending for beneficiaries attributed to a Medicare ACO, according to...

AHA Asks CMS to Waive Medicare Advantage Prior Authorization During PHE

by Victoria Bailey

The American Hospital Association (AHA) has asked CMS to work with Congress and require Medicare Advantage plans to waive prior authorization processes during the current and future public health...

Health Systems Set Sights on Risk-Based Payment in Medicare Advantage

by Jacqueline LaPointe

Health systems are planning to advance their risk-based payment strategies by taking on more upside or downside risk, professional capitation, or global capitation in Medicare Advantage lines of...

AHA Calls for Medicare Advantage Inclusion in Prior Authorization Rule

by Victoria Bailey

The American Hospital Association (AHA) has asked CMS to include Medicare Advantage organizations in its proposed rule that would streamline the prior authorization process and reduce patient care...

Medicare Payments Unfair to Providers Treating Vulnerable Patients

by Emily Sokol, MPH

Medicare’s reimbursement methodology risks unfairly paying providers, hospitals, and Medicare Advantage plans who treat vulnerable populations. In value-based payment models, Medicare uses risk...

High Quality Hospitals Treat Less Medicare Advantage Enrollees

by Samantha McGrail

Medicare Advantage enrollees had a 2.8 percentage point lower probability of being admitted to a highly rated hospital compared to traditional Medicare enrollees, according to a report from Brown...

Trump Seeks to Tie Fee-for-Service to Medicare Advantage Rates

by Jacqueline LaPointe

An executive order signed by President Trump on Thursday directs HHS to explore tying Medicare fee-for-service rates to those negotiated for Medicare Advantage plans and other market-based pricing...

370 Groups Seek Prior Authorization Automation, Reform in MA

by Jacqueline LaPointe

The American College of Rheumatology (ACR), along with 369 other patient, physician, and healthcare professional organizations, sent a letter to Congress on Wednesday calling for prior authorization...

ACOs Save More Compared to Medicare Advantage, Report Finds

by Jacqueline LaPointe

The Medicare Shared Savings Program, which governs the majority of Medicare accountable care organizations (ACOs), and Medicare Advantage are gaining in popularity. But the former is saving taxpayers,...

Risk-Based Revenue Gains Momentum Among Providers, AMGA Finds

by Jacqueline LaPointe

Risk-based revenue from medical groups and integrated delivery systems (IDNs) accounted for 56 percent of revenues in federal settings and 28 percent of revenues in commercial settings in 2018,...

Provider Directory Accuracy Issues Persist for Medicare Advantage

by Jacqueline LaPointe

Online Medicare Advantage provider directories are still not accurate, according to a recent CMS analysis of approximately one-third of Medicare Advantage Organizations (MAOs). In its third round of...

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