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Oct 27, 20238 min read

Why Do Doctors Not Like Medicare Advantage Plans?

Updated: Oct 10

Medicare Advantage Plans have become an increasingly popular alternative for Medicare beneficiaries looking to gain more affordable and comprehensive health coverage. Over 26 million people were enrolled in a Medicare Advantage Plan in 2022, accounting for nearly half of all Medicare enrollees. However, despite the growing prevalence of Medicare Advantage Plans, many physicians have voiced strong opposition and criticism of these private Medicare Plans over the years.

In this comprehensive guide, we’ll explore the key reasons why many doctors do not accept or like treating patients who have Medicare Advantage Plans compared to Original Medicare.

Overview of Medicare Advantage vs Original Medicare

Before diving into the specific physician complaints about Medicare Advantage, it’s helpful to understand the key differences between Medicare Advantage and Original Medicare.

Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance). Under Original Medicare, beneficiaries can see any doctor or hospital in the U.S. that accepts Medicare, without needing referrals or prior authorizations. You simply pay a portion of the Medicare-approved amount for covered services after meeting your deductible when you get sick. However, Original Medicare does not have an annual out-of-pocket limit, so there is no cap on your medical costs each year. Many beneficiaries address this by purchasing supplemental coverage like Medigap Plans.

Medicare Advantage (also called Medicare Part C) allows private insurance companies to offer Medicare benefits to beneficiaries. Medicare Advantage Plans combine Part A, Part B, and usually Part D prescription drug coverage into one plan. They have restricted provider networks requiring you to see in-network providers to get coverage. However, Medicare Advantage Plans offer more benefits than Original Medicare and have an annual out-of-pocket limit to reduce costs. Premiums and cost-sharing also tend to be lower than Medigap and Part D Plans.

Now that we’ve covered the basics, let’s explore the main criticisms doctors have with Medicare Advantage Plans compared to Original Medicare.

Restricted Networks Limit Physician Choice

One of the most common complaints doctors have about Medicare Advantage is that these plans utilize restricted provider networks. Each Medicare Advantage insurer only contracts with certain hospitals, physicians, and other healthcare providers. Enrollees in a Medicare Advantage Plan can only receive non-emergency coverage when seeing in-network providers.

Many doctors argue that these limited networks prevent them from referring patients to the best specialists and facilities for treatment. They dislike being constrained by an insurance company’s contracted network when trying to coordinate optimal care for patients.

For example, if a primary care doctor believes the top cardiologist in the region is out-of-network, they cannot send their Medicare Advantage patient to them without incurring high out-of-network costs. With Original Medicare, they could refer the patient to any appropriate specialist accepting Medicare nationwide.

Research has found that Medicare Advantage networks include just 73% of healthcare providers that accept Original Medicare health plan may offer on average. This can make it challenging for doctors to deliver robust coordinated care when you enroll in medicare.

Prior Authorization Delays and Denials

Another major grievance physicians have with Medicare Advantage Plans is dealing with the prior authorization process required for treatments, procedures, prescriptions, referrals, and advanced imaging.

Doctors must submit documentation to prove the medical necessity of a requested service or treatment before the Medicare Advantage insurer will approve it. This bureaucratic process aims to control utilization and spending. However, doctors argue it simply creates unnecessary delays that can be detrimental to patients’ health.

One survey found 90% of doctors said prior authorizations sometimes or often delay access to necessary care. 75% said prior authorizations have led to a serious adverse event for a patient in their care.

Not only does prior authorization result in treatment delays, but Medicare Advantage insurers often deny or alter physician-recommended care in favor of less expensive alternatives. Doctors dislike when an insurance plan overrules their expert judgement about the most optimal care for their patient.

With Original Medicare, doctors have much more autonomy and flexibility to use their clinical experience to determine appropriate treatments and referrals for patients. They are not bound by an insurance company’s protocols and cost-reduction efforts. This allows them to provide more timely, specialized care guided by a patient’s unique health needs.

Lower Physician Reimbursement Rates

Many doctors also cite lower reimbursement rates from Medicare Advantage Plans as a reason for not participating in their networks or discouraging Medicare Advantage enrollment.

A study by the Kaiser Family Foundation found that Medicare Advantage Plans pay physicians around 93% of Original Medicare rates on average. However, reimbursement rates can vary significantly depending on the plan, region, and provider specialty. Some plans may pay as much as 15-20% less than Original Medicare.

Lower payment rates mean less incentive for doctors to accept Medicare Advantage. The administrative burden of prior authorizations and utilization management make the lower revenue-per-patient even more unappealing.

While Medicare Advantage Plans argue their larger patient pools still lead to overall higher total reimbursement for providers, many doctors remain frustrated with the lower pay rates. They prefer the simplicity of uniform Original Medicare reimbursement.

Greater Financial Responsibility for Patients

Another issue doctors have with Medicare Advantage is the greater financial responsibility placed on patients for their medical care.

Medicare Advantage Plans typically have lower premiums than Medigap policies or Part D Plans. However, they also feature higher deductibles, copays, and coinsurance for many services. There are also penalties for seeing out-of-network providers.

Doctors worry these cost-sharing structures put patients at greater risk of accruing substantial medical debt. This is especially true for patients needing extensive medical services in a year.

One study found the average out-of-pocket limit for Medicare Advantage enrollees was $6,700. That compares to only $2,300 for beneficiaries with Original Medicare plus a Medigap Plan.

Doctors prefer when patients have supplemental coverage with lower cost-sharing that ensures they can actually afford the care they prescribe. With high Medicare Advantage expenses, doctors know patients may delay or avoid care due to financial challenges.

Interference With Medical Decision-Making

Finally, many doctors fundamentally object to the interference with medical decision-making that Medicare Advantage Plans impose through their utilization controls.

As mentioned regarding prior authorizations, doctors dislike when Medicare Advantage Plans overrule or deny their expert judgement on the most appropriate treatments and procedures for a patient's condition. They view insurance companies' pursuit of lower costs as undermining quality medical care guided by years of training and expertise.

Doctors argue that Medicare Advantage Plans denial of specialist referrals, denial of diagnostic tests, substitution of physician-prescribed medications, and delay of surgical procedures based on cost all negatively impact patient health outcomes. They believe clinical decisions should be left to doctors, not insurers.

Doctors widely view Medicare Advantage Plans’ prior authorization requirements, denial of treatments, and substitution of medications as an impediment to their ability to practice medicine ethically and autonomously in their patients’ best interests.

Why Do Some Doctors Still Accept Medicare Advantage?

Given all the physician complaints about Medicare Advantage Plans, you may wonder why any doctors participate in Medicare Advantage networks or accept these plans at all. There are a few reasons some doctors tolerate the challenges of Medicare Advantage:

Significant patient volume makes it impractical not to participate. In many areas over 50% of Medicare beneficiaries are enrolled in MA plans.
Potential for overall higher total patient revenue despite lower per-patient rates.
Recognition that Medicare Advantage provides valuable benefits like drug coverage and capped out-of-pocket costs for patients.
Willingness to navigate prior authorization requirements if it means access to a broader patient population.
Medicare Advantage Plans provide additional services like care coordination and gap closure incentives that help manage complex patients.

How Seniors Can Navigate Doctors Not Accepting Medicare Advantage

As a Medicare beneficiary, it can be frustrating when you join a Medicare Advantage Plan only to find your preferred doctor does not accept it. Here are a few tips for navigating this situation:

When shopping for plans, make sure to see if your current providers are in-network before enrolling. Medicare's Plan finder may offer this information.
Understand that with Medicare Advantage you may need to switch doctors or have a narrower selection than with Original Medicare. Weigh provider choice vs. other plan benefits.
For specialists not in your Medicare Advantage network, ask for a referral or prior authorization to see them out-of-network. This may allow some coverage.
If you need to see an out-of-network doctor regularly, switching back to Original Medicare and a Medigap Plan may be best to maintain the doctor relationship.
Register any complaints about inadequate provider networks with Medicare. This can impact future plan acceptance decisions.
Vote with your feet by choosing Medicare Advantage Plans with broader provider networks when possible. Encourage others to do the same.

While Medicare Advantage has its challenges, it can still be an optimal choice for some Medicare beneficiaries who prioritize low costs and benefits over provider flexibility. But recognizing doctors' objections can help you make an informed Medicare decision.

FAQs

Why do doctors not like Medicare Advantage Plans?

Doctors may not like Medicare Advantage Plans may because they often have a limited network of doctors to choose from. Additionally, these plans may have lower reimbursement rates for providers compared to traditional Medicare.

What are the disadvantages of Medicare Advantage Plans?

Some of the disadvantages of Medicare Advantage Plans include limited network of doctors, potentially higher out-of-pocket costs for certain services, and the need to get referrals to see specialists.

Can I still enroll in a Medicare Advantage Plan if I have a Medicare supplement plan?

Yes, you can still enroll in a Medicare Advantage Plan even if you have a Medicare Supplement Plan. However, you will need to decide whether you want to keep your supplement plan and switch back to original Medicare coverage if you decide to leave the Medicare Advantage Plan.

Why are Medicare Advantage Plans often referred to as bad?

Medicare Advantage Plans are often referred to as bad due to their limited network of doctors, potential for higher out-of-pocket costs, and restrictions on seeing specialists without a referral.

Why do many Medicare Advantage Plans have a limited network of doctors?

Many Medicare Advantage Plans have a limited network of doctors because they contract with specific healthcare providers and often have agreements in place to control costs.

Why do some doctors not like Medicare Advantage Plans?

Some doctors may not like Medicare Advantage Plans because they may have lower reimbursement rates than traditional Medicare, and the administrative requirements of dealing with different plans and networks can be burdensome.

Can I switch back to original Medicare if I don't like my Medicare Advantage Plan?

Yes, you can switch back to original Medicare during certain enrollment periods if you are not satisfied with your Medicare Advantage Plan.

What are the pros and cons of Medicare Advantage Plans?

Some of the pros of Medicare Advantage Plans include additional benefits not covered by traditional Medicare, such as prescription drug coverage. However, some cons include limited network of doctors and potential for higher out-of-pocket costs.

Are there many Medicare Advantage Plans to choose from?

Yes, there are many Medicare Advantage Plans available, but the specific plans offered may vary depending on your location.

What is the worst Medicare Advantage Plan?

The "worst" Medicare Advantage Plan will depend on individual preferences and needs. It is important to carefully review the details of each plan, including network of doctors, coverage, and costs, to determine which plan is best for you.