"I think you're going to see more large provider organizations threaten to opt out of networks, particularly as it relates to MA," Hill said, adding that there are a number of reasons for this. "Prior authorizations are the problem, claims denials are a huge problem, delayed payments and rates are the problem -- barriers in access to care in all varieties are the problem."
Health systems' actions in this area won't necessarily be "all or none," he continued. "There are a lot of intermediate steps. Maybe there's a flagship hospital that can't be used by an MA patient. Maybe there's some type of clinic or some type of service that can't be used by them, or some other type of steerage that goes on ... Given the [financial] pressure that the Medicare Advantage plans felt like they were under in 2023, are going to be under in 2024, and expect to be under in 2025, this is a problem that gets worse before it gets better."
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Health systems' actions in this area won't necessarily be "all or none," he continued. "There are a lot of intermediate steps. Maybe there's a flagship hospital that can't be used by an MA patient. Maybe there's some type of clinic or some type of service that can't be used by them, or some other type of steerage that goes on ... Given the [financial] pressure that the Medicare Advantage plans felt like they were under in 2023, are going to be under in 2024, and expect to be under in 2025, this is a problem that gets worse before it gets better."
More Health Systems Likely to Drop Out of Medicare Advantage, Analyst Predicts
Claims denials, prior authorizations are just some of the reasons, he says
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