Author: Kendall Smith, MD | Chief Medical Officer & Chief Physician Advisor – PayerWatch & AppealMasters
9/9/2024
Medicare Advantage (MA) plans now cover over 30 million Americans, promising to deliver quality care while managing costs more effectively than traditional Medicare. However, as outlined in Becker’s Hospital Review article, “Medicare Advantage’s Unrealized Potential” (https://www.beckershospitalreview.com/finance/medicare-advantages-unrealized-potential.html), the reality hasn’t quite lived up to the promise. Instead, we’re seeing a system that too often leads to denials of care, financial strain on hospitals, and frustration for both providers and patients.
At PayerWatch, we’re in the trenches with hospitals every day, helping them navigate the difficult landscape of insurance denials. The original goal of MA was to streamline care and save costs, but instead, hospitals are facing a rising tide of denied claims. This doesn’t just hurt the bottom line—it disrupts patient care and erodes trust.
More Denials, Less Care
One of the biggest issues with Medicare Advantage is how often medically necessary care gets denied. What’s frustrating is that these are services hospitals provide in good faith, expecting to be paid, only to find out later that claims have been denied after the fact. This forces hospitals to go through a time-consuming and resource-draining appeals process. And when appeals fail, it’s the patients and the hospitals that get stuck with the financial consequences.
At PayerWatch, we see these stories play out every day. Hospitals are already dealing with staffing shortages and tight budgets. Now, add to that a backlog of denied claims, each requiring hours of paperwork and follow-up. This isn’t sustainable for our healthcare system, and it’s certainly not fair to the patients who rely on these services.
Our Veracity™ platform is designed to give hospitals the tools they need to fight back. By using real-time tracking and analytics, hospitals can quickly see patterns in denials and put together stronger, evidence-based appeals. Our goal is simple: to make sure hospitals get paid for the care they provide, and patients receive the treatments they need without unnecessary delays.
It’s Time for Real Reform
We agree with the Becker’s article that reform is needed, but it’s not enough to tweak the system. There needs to be real accountability for MA plans when they deny claims that should have been approved. It’s time for stricter oversight and transparency so that hospitals aren’t left holding the bag when payers deny legitimate care.
Right now, hospitals are footing the bill for these denied claims, putting their financial stability at risk. Worse yet, patients are often caught in the middle, facing delays in getting the care they need. We need clear, enforceable standards to ensure MA plans prioritize patient care and stop hiding behind technicalities to deny claims.
Technology Can Help Bridge the Gap
The good news is that technology can play a big role in solving these issues. With platforms like Veracity™, hospitals can stay ahead of the denial curve, using data to pinpoint denial trends and take immediate action. When hospitals are equipped with the right tools, they can reduce the administrative burden and focus more on delivering care.
At PayerWatch, we believe that hospitals shouldn’t be fighting this battle alone. By empowering hospitals with the tools and expertise to manage denials, we can start making a real difference in how care is delivered and paid for.
Looking Forward
Medicare Advantage has the potential to do great things, but right now, too much of that potential is unrealized. It’s time for the industry to take a hard look at how these plans are working—or not working—for patients and providers alike. At PayerWatch, we’re committed to being part of the solution, helping hospitals push back on inappropriate denials and make sure that care comes first, not profits.
Let’s work together to bring accountability to the system and make sure MA plans live up to their promise. After all, healthcare should be about helping people—not playing games with their care.
