The Changing Medicare Landscape

Medicare Advantage has gained popularity in recent years, and there seems to be no end in sight. While the benefits to consumers are obvious, what complications does this growth bring providers?

Medicare open enrollment is currently underway. Similar to most health insurance plans, new policies began on January 1. As with other healthcare consumers, Medicare users have the opportunity to change their elections in preparation for the New Year.

61 million Americans are currently enrolled in Medicare. In the years since the inception of Medicare Advantage Plans, there has been a noted shift in patients choosing these plans over traditional coverage. This new option has really changed the landscape. It’s estimated that a third of the eligible population has migrated to this plan. By 2030, it’s said that half of the Medicare-eligible population will have converted to Medicare Advantage.

The appeal of Medicare Advantage Plans

Rising out-of-pocket costs are a factor for many Americans. Thankfully, overall conditions are improving for many in recent years, according to a recently released report from CMS. Medicare Advantage plans promise a broader range of services for the same or lower cost than traditional Medicare. If you’re a patient on a fixed income – as many seniors are – this can be big savings. Select Medicare Advantage plans even have premiums as low as $0 (although other costs may arise in the form of deductibles or co-pays). In addition to a premium, enrollees usually pay monthly for the plan’s medical and prescription drug coverage. While patients may pay a little more, the benefits seem to be worth it. Simplified, Medicare Advantage can be thought of as an expanded program that reduces costs for Medicare enrollees.

The plans cover the same services as original Medicare, and emergency and urgent care services are always covered. Many plans also offer extra benefits such as dental care, vision care, wellness programs and prescription drug coverage. Even transportation – a service that is seldom covered, yet critical for many seniors that may be unable to drive – is included in some instances. The “complete package” option offered by Advantage really is seen as the least confusing option by many patients.

Increased enrollment, increased issues

In the past, Medicare has represented approximately 20-25% of the claims TriZetto Provider Solutions has received. As the Medicare-eligible population has grown in recent years, so has that number. So what does this mean for providers? Increased enrollment adds more complexity to provider workflow.

When patients change plans, inaccurate eligibility information can lead to a high risk of denials. Let’s say a new patient has misplaced their insurance card. If they forget to bring their new card to an appointment, or recently changed insurance and have yet to receive a new card, they may be listed as ineligible. Or perhaps a patient sees their plan simply as Medicare and does not realize that their new Advantage plan has differences from the previous one. Maybe the patient has selected a Medicare Advantage plan that has in-network requirements. If the patient has a new plan that places their existing provider out of network, it’s critical that the provider finds this out before treating the patient or they likely won’t get paid. Referrals to specialists will have similar complications and will take time for your staff to reconcile.

These are all scenarios that prove why eligibility is so important. Without checking eligibility before the visit, the claim will be directed to the incorrect plan, which will require staff intervention and delay reimbursement. In these cases, understanding up-to-date eligibility information is a must-have in your pre-treatment workflow.

Best practices for providers: Increase transparency with accurate estimates

What can provides do ensure accurate eligibility? The most effective approach is to prevent issues before they arise. This includes using electronic eligibility and reviewing any invalid responses beforehand. Doing so will limit the risk of unpaid claims and denials. Financial risk and frustration that are unfortunately common with health insurance. For many Americans, understanding medical bills can be confusing and there is an underlying fear that you won’t be able to pay a medical bill. Accurate coverage and payment estimations benefit the patient by painting an accurate picture of their financial responsibility. This also benefits providers, as the transparency eliminates surprise bills and creates satisfied patients.

While insurance policies may change, the challenges for providers remain the same – how to adequately gain accurate reimbursement. Given the growing number of Medicare Advantage users, it is critical to access accurate coverage and patient financial responsibility estimates. Thankfully eligibility services from TriZetto Provider Solutions, a Cognizant Company, allow medical practices to determine coverage before the time of service. This helps avoid the time-consuming hassle of having to dive into discrepancies after an appointment, or worse, after receiving a denial. Stay ahead of Medicare Advantage-related denials and save your practice unnecessary time and frustration.

For additional reading, access our resources page and discover our recent article detailing how practices can overcome eligibility woes.