determining Medicare Advantage eligibility

Medicare Advantage enrollees face challenges getting accurate network information

It’s no surprise to healthcare providers that enrollment in Medicare Advantage plans is growing. But for some patients, the smaller networks of providers in these plans may be unwelcome news—even if they think they’ve done their due diligence before selecting a plan.

That’s the takeaway of a recent Reuters article, which reported that the lists of providers in the HMOs and PPOs that make up Medicare Advantage plans are often inaccurate or difficult to understand. The article cites data from the Kaiser Family Foundation, which stated, “information about hospital networks [in Advantage plans] is not readily available, sometimes inaccurate and rarely consumer friendly.” The Foundation points out that provider directories are not posted on the plan-finder tool; and that of the 231 provider directories that it examined for its study, 11 included hospitals that had been closed.

The findings underscore the need for providers to perform accurate and efficient eligibility checks, given the data which patients have access to can often be unreliable. With 31 percent of this year’s Medicare participants enrolled in an Advantage plan, admissions and billing representatives should be ready to answer questions and provide guidance. The Congressional Budget Office projects that 41 percent of Medicare enrollees will use Advantage plans by 2026, making it even more important for the industry to improve the transparency and accuracy of directories.

The issue has already been noted by the Government Accountability Office, which released a report last year stating that CMS should improve its oversight of Advantage plans to ensure that both networks and provider directories are adequate. In the meantime, the onus is on providers and patients to make sure that coverage is clearly understood.


To see an on-demand webinar about how ABILITY can help providers with eligibility confirmation, click here.