The Impact on Private Practices as Hospitals and Health Systems Go Out of Network with Medicare Advantage

In recent years, private practices nationwide have witnessed significant changes in healthcare insurance networks, particularly with Medicare Advantage. A growing number of hospitals and large health systems opt out of Medicare Advantage plans, and the ripple effects are being felt across the industry.

These changes bring both opportunities and challenges for private practices. As hospitals go out of network, patients enrolled in Medicare Advantage are increasingly turning to private practices for care. However, with this shift comes a need for practices to rethink their approach to patient demand, billing, and reimbursement.

In this blog, we’ll examine how this trend may impact your practice and explore steps you can take to stay ahead.

What Happens When Hospitals Leave Medicare Advantage Networks?

Medicare Advantage, a popular alternative to traditional Medicare, is known for offering lower out-of-pocket costs, prescription drug coverage, and extra benefits. However, it also requires members to stick to a limited network of providers for maximum coverage. When hospitals and health systems go out of network, these facilities will no longer accept Medicare Advantage insurance, leaving patients to cover higher out-of-network costs if they seek care there.

So why are hospitals making this choice? The primary reasons are financial and administrative. Medicare Advantage plans, which private insurance companies manage, often pay lower rates to hospitals than traditional Medicare. This can make it financially unfeasible for hospitals to participate. Moreover, dealing with Medicare Advantage’s specific administrative requirements can be burdensome, which is why some hospitals opt-out.

These shifts mean fewer options within patients' insurance networks. For private practices, it means a potential increase in Medicare Advantage patients seeking care in your office.

Rising Patient Demand in Private Practices

One immediate impact of hospitals going out of network is the potential rise in demand for private practice services. Patients who previously visited a hospital or extensive health system for care may now seek private providers for their healthcare needs.

This change brings unique opportunities and responsibilities for private practices. Increased patient demand can lead to new revenue streams and a broader patient base but also requires preparation. Taking on more patients without adequate infrastructure or support can overwhelm your team and reduce the quality of care.

To make the most of this opportunity, it's essential to evaluate your current workflows and ensure your practice can meet the demand. Think about staffing needs, patient scheduling, and the capacity of your administrative team to handle billing and insurance claims. If you’re prepared, this can be a great way to expand your reach and make a difference for more patients.

Navigating Medicare Advantage Reimbursement Challenges

Working with Medicare Advantage brings its own set of billing and reimbursement challenges. While traditional Medicare follows a standardized fee schedule, Medicare Advantage plans vary in reimbursement rates and requirements. Some plans reimburse at rates lower than traditional Medicare, impacting your practice’s revenue.

It’s critical to be proactive in verifying eligibility, benefits, and the out-of-pocket costs patients will incur with their specific Medicare Advantage plan. Checking this information upfront can help prevent unexpected billing issues and improve patient satisfaction. Patients are often unaware of network limitations and costs, so it’s up to your practice to set expectations early.

One challenge practices face is keeping up with the nuances of each Medicare Advantage plan. Differences in coverage, prior authorization requirements, and reimbursement rates can create significant administrative complexity. A dedicated billing team understanding these nuances can save time and reduce errors, leading to better financial outcomes for your practice.

Understanding the Needs of New Medicare Advantage Patients

Patients seeking alternative care after their hospital goes out of network may have unique healthcare needs. Many patients rely on Medicare Advantage for ongoing treatment, chronic care management, and specialized services. As a result, your practice may encounter patients with more complex medical histories or a higher need for care coordination.

This shift may require some adjustments to your current processes. For instance, your team might need additional training to manage chronic conditions more effectively, or you may need to add specific services to meet the demand. Additionally, it’s essential to anticipate and address Medicare Advantage patients' specific expectations—such as clarity around costs and understanding their coverage limits.

Investing in the skills and resources to meet these patient needs can build trust and loyalty. Patients who feel cared for and informed will likely continue their relationship with your practice, even after insurance network options stabilize.

Best Practices for Private Practices Working with Medicare Advantage

Taking on Medicare Advantage patients successfully requires careful planning and execution. Here are some best practices that can help your practice deliver quality care while navigating the administrative side of Medicare Advantage:

Implement Strong Verification Processes: Before each visit, verify the patient’s Medicare Advantage plan, network status, benefits, and costs. This will help avoid claim denials and ensure your services are paid accurately.

Educate Patients on Billing and Coverage: Medicare Advantage patients often don’t realize the extent of out-of-pocket costs associated with out-of-network providers. Clear, open communication about coverage, fees, and payment options can help build patient trust and prevent confusion.

Invest in a Dedicated Billing Solution: Medicare Advantage billing can be complex. Having a dedicated billing solution or partner ensures that claims are submitted accurately, reducing the chance of denials or delays in payment. This also allows your administrative team to focus on patient care rather than the intricacies of Medicare Advantage billing.

Stay Current on Plan Changes: Medicare Advantage plans frequently change their requirements and reimbursement rates. Staying up-to-date on these changes can help you avoid billing mistakes and smooth your revenue cycle.

Consider Outsourcing Your Billing: Billing for Medicare Advantage requires time and expertise. Outsourcing your billing to a team specializing in these processes, like Practice Solutions, can alleviate administrative burdens, increase efficiency, and improve your financial outcomes. A dedicated billing partner can take care of eligibility checks, claim submissions, and follow-up with payers, freeing you up to focus on patient care.

How Practice Solutions Can Support Your Practice

As hospitals go out of network with Medicare Advantage and patient demand shifts, it’s more important than ever for private practices to streamline their billing and revenue cycle processes. Practice Solutions specializes in helping practices navigate complex insurance requirements, especially regarding Medicare Advantage.

Our team of billing experts understands the unique challenges Medicare Advantage presents. We manage the entire claims process—from eligibility checks to reimbursement follow-up—so you don’t have to. This means less time spent on paperwork and more time to provide quality care to your patients.

Let Us Handle the Billing—You Focus on Patient Care

If you’re seeing an influx of Medicare Advantage patients and want to ensure your practice is ready to meet their needs, consider partnering with Practice Solutions. Our services can improve your revenue cycle, reduce claim denials, and ensure you’re accurately reimbursed for every service you provide. Reach out today to learn how we can support your practice in this changing landscape.

Conclusion

The trend of hospitals and health systems going out of network with Medicare Advantage is reshaping the healthcare landscape. For private practices, this change offers a unique opportunity to grow their patient base, but it also comes with challenges around billing, reimbursement, and patient expectations.

By proactively adapting to these changes, you can position your practice for success. With the right approach, your practice can provide essential care to Medicare Advantage patients while maintaining a smooth, efficient revenue cycle. By partnering with Practice Solutions for your billing needs, you can rest assured that the administrative side is covered, allowing you to focus on what you do best: exceptional patient care.