Medicare Advantage for Independent Practices

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Programs like Medicare Advantage have become critical for physicians as the healthcare industry continues to shift from fee-for-service to value-based care and they are only expected to increase in value to patients.

The Centers for Medicare and Medicaid Services (CMS) announced that it will further reduce Medicare Advantage premiums while expanding coverage for additional services in 2021. These new benefits will be offered in addition to the Medicare Advantage program’s existing valuable services such as medication assistance, transportation, and disease management programs.

The program is only growing. Projections show that by 2025, the number of MA enrollees will comprise 40 percent, or 30 million, of all Medicare patients. With Medicare Advantage premiums at their lowest point, independent physicians may want to adjust their practice to accept new Medicare Advantage patients. MA can help physicians provide high-quality care to their patients and improve their health outcomes.

However, the program requires time and upfront investment. What should physicians consider before making the switch?

Pros of Medicare Advantage for Independent Practices

Unlike traditional Medicare, Medicare Advantage is administered by private insurance companies and includes additional medical expenses like prescription drugs. The program shifts the burden of risk to an accountable physician and ties physician reimbursement with patient outcomes. This structure has proven to result in healthier patients and reduced healthcare expenses.

The plans also shift the focus to preventive care, making the primary care physician the key point of contact for the beneficiary’s medical needs. Primary care physicians must approve referrals, which helps control costs while ensuring continuity of care outside of the independent practice.

For physicians who are worried about sustaining their independent practices, studies have shown that Medicare Advantage reimburses physicians at roughly the same rate as traditional Medicare for the same services. Medicare Advantage patients pay a premium for a health plan to manage their services, but increases in these administrative costs have decelerated.

Areas of Opportunity in Medicare Advantage

To achieve success in MA programs, it will be critical for physicians to understand and learn how to properly code their patient encounters. In 2020, The Office of Health and Human Resources’ (HHS) Office of Inspector General (OIG) discovered that CMS received a total of $14.4 million in overpayments from Medicare Advantage beneficiaries due to physician coding errors. 

According to Healthcare Finance, the OIG determined many of these errors came from codes that had a “high risk of being miscoded.” The OIG encouraged CMS to reassess its training and further educate physicians as to correct coding. Independent physicians eager to accept new Medicare Advantage patients at this time should be aware of the risk of coding errors and work diligently to avoid them.

Getting Involved

The Medicare Advantage program can be highly beneficial to patients and physicians alike, but it involves a steep learning curve. To get started, physicians will need the following:

  • Ongoing Education. Physicians interested in Medicare Advantage will benefit from additional education prior to making their decision. If a physician decides to accept Medicare Advantage patients, there will be a need for ongoing education. The operational nuances of the program can be quite challenging, ranging from coding to data analysis.
  • Teamwork. It takes a team to care for a Medicare Advantage population. Physicians will need to formulate a strategy with their office staff, nurses, physician assistants, nurse practitioners, and additional healthcare professionals to keep track of hospital visits, hospital readmits, and other factors among their Medicare Advantage patients.
  • A Partner. The right partner should understand the nuances of Medicare Advantage and have the tools, talent, and technology needed to implement it in an independent practice. With a partner, physicians will not have to do everything themselves. Their partner can hold them accountable for deadlines, keep them on track, and update them accordingly if there are changes to the Medicare Advantage program. Additionally, partners can help physicians interpret their data and put together strategies to help them succeed.

Medicare Advantage is a valuable program to consider as healthcare transitions from fee-for-service to value-based care. With its additional service offerings and future outlook, it would be valuable for independent physicians to research the benefits of accepting Medicare Advantage patients, and what structural changes this may mean for their practices. 

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