Pay Change Could Wreck Medicare Advantage Provider Networks, Group Predicts

Physician group practices that participate in new Medicare payment programs say proposed changes could push many doctors out of Medicare Advantage plan provider networks.

America’s Physician Groups, an organization that represents 360 of the practices, predicts that the changes could slash pay for physicians who care for older, sicker Medicare Advantage plan enrollees by 10% to 20%.

“As a result, hundreds of thousands of vulnerable Medicare Advantage enrollees could lose needed access to care,” the organization says.

The organization is calling for the Centers for Medicare and Medicaid Services — the federal agency in charge of Medicare — to put off implementing the changes until 2025, at the earliest.

What It Means

If proposed changes work as America’s Physician Group predicts, they could disrupt some clients’ Medicare Advantage coverage and make use of Medicare supplement insurance more appealing.

The Basics

Medicare Advantage plans cover 30 million of the 65 million U.S. residents with Medicare coverage.

The Centers for Medicare and Medicaid Services uses a risk-scoring system to provide extra cash for plans that cover older, sicker patients.

The Change

CMS fears that Medicare Advantage plans are hurting the risk-adjustment system by working too hard to code for common chronic conditions such as diabetes, arthritis and lupus.

To adjust for high Medicare Advantage plan risk scores, CMS wants to stop including 2,300 diagnostic codes that are used much more often by Medicare Advantage plan providers than by providers who treat Medicare fee-for-service patients.

The move would include the codes for conditions such as major depressive disorder, diabetes with chronic conditions, vascular disease, rheumatoid arthritis and lupus.

Susan Dentzer, the CEO of America’s Physician Groups, called that proposal “supremely irrational.”

Physician group practices believe that “caring for disadvantaged Medicare Advantage enrollees will no longer be viable, and that they will have no choice but to abandon them and return to fee-for-service Medicare payment, which remains largely unaccountable for total costs and quality,” Dentzer said.