Why Do Doctors Not Like Medicare Advantage?

Frustrated doctor who doesn't like Medicare Advantage plans

Medicare beneficiaries who take their new Medicare Advantage ID card to their doctors are sometimes met with resistance. Administrative team members and providers often tell their patients that they don’t like Medicare Advantage and encourage them to switch their plans. 

But why? If a doctor is contracted with the plan, why would they say they don’t like Medicare Advantage? Let’s talk about it.

What Is Medicare Advantage?

Let’s start by defining what Medicare Advantage is so that we can better understand why some doctors don’t like it.

Medicare Advantage, also referred to as Part C, is another way to get Medicare benefits. Medicare Advantage plans combine all your benefits from Parts A and B into one plan. They often include extra benefits you won’t get from Original Medicare. That may include dental coverage, vision and hearing care, gym memberships, over-the-counter stipends, and more.

To add to this attractiveness, most Medicare Advantage plans have low premiums, many times as low as $0 per month. Sounds nice, right? Medicare Advantage plans can be a great fit for many beneficiaries. So why do doctors not like Medicare Advantage?

The Problem with Medicare Advantage

No insurance plan is perfect, and Medicare Advantage plans come with their own set of problems. There are a few reasons you may not want to enroll in Medicare Advantage.

First, you may experience more out-of-pocket costs. It’s true that the monthly premiums are often low, but that doesn’t mean Medicare Advantage is free. The plan will provide you with a list of covered services and the copayment associated with them. For example, a visit to your doctor may cost $20, and an ambulance ride may cost $300. (Every Medicare Advantage plan is unique, so be sure to read the summary of benefits.)

Depending on your health, you could end up with quite a few out-of-pocket costs. So, while you might have saved on the monthly premium, you may end up paying more than you would have had you stayed with Original Medicare and added a Medigap plan. Fortunately, all Part C plans also have a maximum out-of-pocket limit, so your spending is capped.

Second, you’ll be restricted to a certain network of providers and facilities. This is one way insurance carriers control their costs. For example, if you enroll in a Health Maintenance Organization (HMO) Medicare Advantage plan, you can only see providers who contract with that particular plan. HMO plans do not offer any coverage outside of the network except in emergency situations. This can lead to unexpected medical bills if you’re not paying attention.

Finally, let’s discuss the number one reason doctors don’t like Medicare Advantage: prior authorizations.

Prior authorizations are the primary way insurance companies control their costs. A prior authorization is something that must be obtained before services can be rendered. Not all services will require a prior authorization. For example, you won’t need prior authorization before making a routine checkup appointment. However, invasive and expensive procedures will almost always require prior authorization.

In theory, this isn’t a bad thing. Insurance carriers want to ensure providers aren’t overdiagnosing or jumping to conclusions. Wouldn’t you prefer a less invasive procedure before undergoing major surgery? 

The problem is that your insurance company isn’t your doctor. They don’t know what’s best for you, and doctors are frustrated that they get to dictate the care you receive. Prior authorizations require lots of paperwork and delay necessary treatment. If treatment is denied, you’re left to decide if you want to forgo a needed procedure or pay out of pocket.

Prior authorization for Medicare Advantage plan

Get Your Medicare Questions Answered

Medicare Advantage plans are a great option for many people. Regardless of which kind of Medicare plan you choose, you need to fully understand the pros and cons of your choice. This way, you’ll be prepared as things come up and will know how to handle a medical situation best.

The team at Carolina Senior Benefits has you covered. Our Medicare advisors will teach you about each kind of Medicare plan and will help you during the decision-making process. There is absolutely no cost to work with our team. Call and speak to an advisor today!