Medicare Advantage (MA) payers are increasingly denying claims and pressuring health systems to accept lower reimbursements. This trend is not only straining health system revenue but escalating administrative burdens, prompting many to reconsider or terminate their MA contracts. In this blog, we’ll dive into the current state of MA challenges, and outline tools and strategies that can help health systems respond to these challenges.
The MA Problem
Historically, MA was one of the most profitable business lines for payers — but this trend has been continuously declining. As a response, payers are taking action that negatively impacts health systems and their bottom line. For example, in some markets, payers are pushing MA rates below Medicare Fee-For-Service (FFS). Additionally, payers are increasing MA related denials and prior authorization requirements, leading to overall drops in yield in MA contracts for health systems.
Because of this pattern of delays and denials, top payers, such as UHC and Humana, are facing lawsuits for inappropriate care denials.
We’re also seeing some hospitals and health systems opt to end their contracts with MA plans over these administrative challenges — commonly citing excessive prior authorization denial rates and slow payments from insurers.
For health systems not going out of network, a strategy needs to be developed for negotiating contracts and taking on MA risk to maintain existing payer relationships. This is easier said than done, as many existing systems don’t provide the data insights needed to inform an effective strategy. Teams don’t have a tool that demonstrates meaningful payer trends, like denial or underpayments reports, which makes it increasingly difficult to develop strong negotiation tactics.
That’s where Adonis Intelligence comes in.
The Intelligent Solution
Adonis Intelligence is an AI-driven revenue cycle platform that delivers actionable alerts, predictive analytics, and real-time reports.
There are two main areas where Adonis Intelligence can help health systems facing MA challenges: managing denials and administrative burden, and developing a payer strategy.
- Managing denials and easing administrative burden: Adonis Intelligence leverages machine learning to proactively predict and prevent denials. This ability to identify incoming denials from MA payers ahead of time will give health systems an upper hand and enable them to respond and adjust their claims as needed to mitigate many of these denials. Reducing denial rates for MA plans would offset overall revenue loss and keep these health systems from having to drop MA plans from coverage.
- Developing a payer strategy: Through Intelligence’s real-time reporting and KPIs, health systems will be able to identify MA payer specific trends such as denials and underpayments. This actionable data can arm health systems with the data that they need to negotiate payer contracts and specifically address MA payer denials. These KPIs can also help teams defend against the administrative burden of requesting medical records for prior authorizations.
To Summarize
In summary, Medicare Advantage has historically been a profitable business line for payers, but this continues to decline, resulting in significant revenue loss for health systems. Adonis Intelligence can help revenue cycle teams predict and mitigate an influx of denials, while arming health systems with the reporting and KPIs to best negotiate payer contracts in response to these MA related challenges.
Learn more about Adonis Intelligence, here.
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