How does hospital participation in a Medicare Advantage preferred network impact commercial reimbursement?

How does a hospital’s participation in a health plan’s Medicare Advantage (MA) provider network impact their commercial rates? Since many insurers offer both MA plans and commercial plans, there could be spillovers with respect to negotiating. How would MA network participation impact commercial rates? Marr et al. (2025) offers some hypotheses: On the one hand,…

Risk Adjustment and Incentives for Upcoding in Medicare

To account for differences in disease burden across a Medicare Advantage (MA) plans patient population, uses risk adjustment based on patient disease burden. Specifically, MedPAC notes that: Medicare uses beneficiaries’ characteristics, such as age and prior health conditions, and a risk-adjustment model—the CMS hierarchical condition categories (CMS– HCCs)—to develop a measure of their expected relative…

How restrictive are Medicare Advantage plans?

Now that 51% of Medicare beneficiaries are enrolled in Medicare Advantage (MA), one key question is how restrictive are MA narrow networks? While beneficiaries enrolled in Medicare fee-for-service can choose any provider, MA plans can impose restrictions on enrollee’s provider choices. Measuring how restrictive an MA plan is, however, is difficult because “restrictiveness” is a…

Patients love Medicare Advantage, but do providers?

Just this year a majority of Medicare beneficiaries enrolled in a Medicare Advantage plan. While these plans are popular with patients, I recently wrote that some rural providers are refusing to accept Medicare Advantage due to low reimbursement. A recent article from Kaiser Health News finds that provider frustration with Medicare Advantage is spreading to…

Medicare Advantage is taking over

Via the Kaiser Family Foundation: In 2023, more than half (51%) of eligible Medicare beneficiaries – 30.8 million people out of 60.0 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has jumped from 19% in…