As more hospitals and health systems grow frustrated with Medicare Advantage plans, Ascension is among the organizations rethinking how — and whether — to continue participating. Delays in care, high denial rates and growing administrative burdens are prompting tougher contract negotiations and, in some cases, decisions to go out of network.
Eduardo Conrado, president and CEO of St. Louis-based Ascension, told Becker’s the Medicare Advantage program has strayed from its original purpose: providing better benefits and more efficiency for seniors. He argues it has become a source of friction for health systems and a point of confusion and stress for patients — many of whom aren’t fully aware of the restrictions until it’s too late.
In this Q&A, Mr. Conrado discusses why Ascension is scrutinizing Medicare Advantage plans more closely, what its own data reveals about denial rates compared to traditional Medicare, and how the health system is preparing for future contract talks. He also shares insights on guiding patients through Medicare choices and what needs to change at the federal level to bring the program back in line with its promise.
Question: Becker’s has reported on a growing number of hospitals and health systems that are going out-of-network with Medicare Advantage plans due to excessive prior authorization denial rates and slow payments from insurers, among other challenges. What specific challenges has Ascension encountered with Medicare Advantage plans that have prompted closer scrutiny or reconsideration of participation?
Eduardo Conrado: Congress created Medicare Advantage to deliver better benefits, broader coverage and lower costs for seniors. Too often, that is not what patients experience. Instead, they face delays and denials that get in the way of timely care. Despite significant growth, Medicare Advantage has not delivered better health outcomes or greater system efficiency. Our data shows that Medicare Advantage plans are 70% more likely than traditional Medicare to deny claims due to incomplete medical records and twice as likely to deny based on medical need.
Most of those denials are overturned on appeal. That process creates unnecessary stress for patients and delays in care. It also pulls doctors and nurses away from patient care and into administrative back and forth with insurers. These challenges are why we are taking a closer look at how these plans operate and what that means for the communities we serve.
Q: We’ve seen more health systems take a firmer stance in contract negotiations with MA plans and in some cases going out of network to bring payers back to the table with more equitable terms. Ascension Wisconsin recently went out of network with UnitedHealthcare before reaching a new deal in mid-October. What were the turning points in the negotiation that helped get the deal over the line? What advice would you give to other systems negotiating with MA payers over new contracts?
EC: A significant number of the patients we serve in Wisconsin are enrolled in UnitedHealthcare’s Medicare Advantage plan. Our responsibility is to those patients first, and that means making sure our agreements with insurers support the care they rely on. The care our teams provide every day to UnitedHealthcare’s Medicare Advantage members was an important part of the conversation, especially as open enrollment approached. That focus helped move the discussions forward and reach a new agreement.
Q: How is Ascension thinking about its leverage in these negotiations this year? How has your strategy evolved as payer dynamics have shifted?
EC: Our commitment to our Medicare Advantage patients is built on four pillars that guide how we work with payers and advocate for those we serve, including prioritizing patient access, reducing unnecessary care delays, streamlining prior authorization, and ensuring clear and transparent choices. As contracts come up for renewal, we will continue to push for better Medicare Advantage policies around paperwork, approvals and denials, and we are prepared to hold firm on these expectations. We will focus on payers willing to work with us to support sustainable care for Ascension’s patients enrolled in Medicare Advantage plans.
Q: Some health systems are proactively steering patients toward traditional Medicare before they turn 65 to avoid future MA-related access or reimbursement issues. Is this something Ascension is doing, and if so, what results have you seen?
EC: Serving our patients is our top priority. We became concerned as delays, denials, and late payments grew more common in Medicare Advantage, and as patients enrolled in these plans before fully understanding their options. Once enrolled, it can be difficult to return to traditional Medicare. That is why we adjusted our approach. We now offer a voluntary service to help patients understand the difference between traditional Medicare with a supplemental plan and Medicare Advantage. Early results show more patients choosing traditional Medicare than we have seen in the past.
Q: What is your broader assessment of the Medicare Advantage model today? Does it still work for hospitals and health systems, and what needs to change?
EC: When Congress created Medicare Advantage, the goal was to offer seniors and people with disabilities better benefits, more choice, and greater efficiency than traditional Medicare. Over time, prior authorization requirements, denials of care ordered by physicians, and ongoing payment delays have moved the program away from that goal. These practices do more than create financial pressure. They get in the way of care and pull physicians away from their patients to handle administrative issues. We need changes that protect the patient-doctor relationship and allow care to be delivered and paid for when it is needed.
