Medicare Advantage provides coverage to more than 51% of the nation’s seniors, but many hospitals and health systems are pushing back against commercial programs, with some dropping contracts with private plans altogether.

Excessive prior authorization denial rates and slow payments from insurers are some of the biggest challenges providers face with MA programs, but St. Louis-based Mercy CFO Cheryl Matejka maintains that MA is a good model when structured appropriately.

“It helps keep incentives aligned if commercial contract terms are appropriate. Patients like the model in our markets and, I would argue, across the country,” Ms. Matejka told Becker’s. “We want to adapt to serve our communities, and our patients that like those models. That being said, the model needs some tweaks.”

The infrastructure to manage Medicare risk can be daunting, especially for health systems that are new in the MA space or if a particular MA model is new in their market. 

“If you’re just starting down that road while the entire healthcare industry is in the process of financial recovery, building that model can be a daunting cost,” Ms. Matejka said. “Mercy has been building its structure since the late 1990s related to the physician demonstration projects with one of the early models in our Springfield market. We believe it’s a model that can help us as the nation reduces the overall cost of care, but only if it’s structured appropriately and when there’s a win-win for everyone involved.”

Beginning in 2024, MA plans must provide coverage for an inpatient admission when the admitting physician expects the patient to require hospital care for at least two midnights — otherwise known as the two-midnight rule.

Under CMS’ final rule, published April 5, inpatient admissions are covered for traditional Medicare beneficiaries who require more than a one-day stay in a hospital or who need treatment specified as inpatient only. 

However, several MA plans continue to disregard this directive, according to Ms. Matejka.

“When we bill for something, whether it’s inpatient or outpatient, we need to be paid for that,” she said. “The government is also trying to address some of the challenges around preauthorization. With preauthorizations or authorizations for post-acute care — whether that be home care or skilled nursing care — it’s clear there are some challenges with that happening efficiently within the system.”

Addressing these issues is critical so that MA works for all involved: patients, providers and payers. 

“We’re trying to do the right thing for the patients: making sure they’re getting the right level of care and getting care when they need it. To enable the timely care that patients need, payers need to address the timeliness of the authorization process and correctly pay versus deny appropriate levels of care,” Ms. Matejka said. 

“As many of our communities age, we need a financially sustainable model to care for them. Medicare Advantage has a lot of promise there,” she said. “Fortunately, we’ve already built that infrastructure to manage risk but some of those other issues around denials need to be addressed.”