The Hidden Costs of Medical Care

In recent years, Medicare Advantage (MA) plans have gained popularity among seniors due to their low premiums and bundled perks. But while they may seem attractive to enrollees, doctors across the country are sounding the alarm. From excessive paperwork to delayed reimbursements and limited networks, many physicians argue that Medicare Advantage plans create more problems than they solve.

Here’s why so many doctors are frustrated with the current state of Medicare Advantage—and what patients need to understand before choosing a plan.

1. Administrative Burdens Delay Patient Care

Doctors overwhelmingly cite prior authorizations as one of the most frustrating elements of Medicare Advantage. These plans often require approval for a wide range of services, including basic lab tests, MRIs, outpatient surgeries, and even prescription medications.

To navigate this red tape, the average medical practice must employ at least two full-time staff members just to handle prior authorizations. This administrative burden increases overhead costs and takes time away from patient care. And with over 3,800 MA plans in the market, each with its own unique rules, even seasoned providers struggle to keep up.

In contrast, Original Medicare and supplemental Medigap policies rarely require prior authorizations, resulting in fewer delays and a smoother experience for both patients and providers.

2. Lower and Slower Reimbursements Hurt Practices

Medicare Advantage plans typically reimburse doctors at about 85% of what they’d receive under Original Medicare. Not only are payments lower, but they’re also slower. While Medicare pays claims within weeks and Medigap plans within days, MA plans often delay payments for weeks or even months, putting financial stress on smaller practices.

This reimbursement gap makes it harder for providers to sustain their practices, especially those serving a high volume of MA patients. Many report losing money on certain procedures or patients due to these reduced rates.

3. Limited Provider Networks Frustrate Patients and Providers

One of the most common complaints about Medicare Advantage is its restricted provider networks. Unlike Original Medicare, which is accepted by 99% of non-pediatric physicians and nearly all hospitals nationwide, MA plans use HMO and PPO networks that significantly limit provider choice.

Studies show that only 22% of MA plans give access to 70% of doctors in a metro area. Worse, 43% of plans limit access to just 50% of doctors. These limitations make it difficult for patients to keep their preferred providers and often force them to switch plans or pay out-of-pocket for care.

4. Denials of Necessary Care Are Far Too Common

Government audits have found that Medicare Advantage plans deny medically necessary care more often than Original Medicare. From delaying knee replacements and chemotherapy to refusing approval for PET scans and stents, the consequences of these denials can be severe.

Doctors argue that these decisions often come from insurance administrators rather than clinicians. This not only undermines their professional judgment but also puts patients at risk by delaying critical treatments.

5. Profit-Driven Policies Undermine Medical Judgment

MA plans use utilization management tools—such as step therapy, quantity limits, and algorithm-driven care decisions—to cut costs. Unfortunately, these systems often prioritize insurer savings over patient well-being.

For example, some MA plans prematurely discharge patients from skilled nursing facilities, regardless of medical advice. Others require patients to “fail first” on cheaper medications before authorizing the doctor’s recommended treatment. These policies not only frustrate doctors but also jeopardize outcomes.

6. Real-Life Consequences of Medicare Advantage Barriers

The data may be compelling, but the real-world stories are even more telling:

• A breast cancer patient experienced delayed treatment when her MA plan denied a PET scan, allowing her cancer to progress.
• A cardiac patient waited overnight in the ER for MA approval for a stent—a delay that risked his life.
• A patient with severe depression was left waiting three months to see an in-network psychiatrist.
• A hip surgery patient was discharged early from rehab due to plan limits, only to fall at home and suffer a hip fracture.

Each of these cases underscores how insurance interference can create dangerous and unnecessary hurdles.

7. What Doctors Are Saying Across Specialties

• Primary care doctors: Report heavy paperwork and difficulty getting even routine tests approved.
• Cardiologists: Face delays for stress tests, imaging, and post-operative medications.
• Oncologists: Experience frequent denials for advanced imaging and lifesaving chemotherapy.
• Orthopedic surgeons: Encounter delays for MRIs, surgeries, and rehabilitation.
• Mental health providers: Battle limited access to psychiatrists and prior authorizations for medications.
• Geriatric care specialists: Warn of tight limits on home health care and skilled nursing, even when patients clearly need more support.

Final Thoughts: What Patients Should Know

While Medicare Advantage plans may offer lower premiums and appealing extras like dental or vision, it’s important to weigh those perks against the real-world consequences. If your doctor is reluctant to accept your plan or you face frequent delays in care, those savings may come at a high cost.

Doctors aren’t just complaining for the sake of it. They’re raising alarms because these plans often interfere with their ability to care for patients effectively. If you’re considering Medicare Advantage, take the time to understand how your access to care—and your doctor’s ability to provide it—might be affected.