All Articles Healthcare Insurers AHA advocacy highlights concerns with MA plans

AHA advocacy highlights concerns with MA plans

Payment and prior authorization processes continue to create challenges for rural hospitals, leaders say.

3 min read


Samuel Gabriel/Pixabay

The American Hospital Association’s 2024 Rural Advocacy Agenda takes aim at Medicare Advantage plans because of continued concerns with payments and prior authorization procedures that add to providers’ administrative workload.

AHA President and CEO Rick Pollack told the group’s annual Rural Health Care Leadership Conference in Orlando, Fla., that the association will work to ensure timely MA payments to hospitals and address delays and denials that affect patient care. 

Pollack said there has been significant growth in MA enrollment and rural hospitals do not have the infrastructure to challenge claim delays and denials, which are “putting a real squeeze on hospital reimbursement, particularly for critical access hospitals, where these plans are not held to the same standards or requirements as the regular Medicare program.”

The AHA wants cost-based reimbursements from MA plans. While CAHs have a special statutory payment designation to help support rural health care services, more of their revenue is subject to negotiated rates in MA plans.

Travis Robey, the AHA’s vice president of political affairs, said 40% of Medicare beneficiaries in rural areas are in MA plans, four times the rate in 2010, so failing to provide cost-based reimbursements means that “Medicare is not fulfilling its promise of cost-based reimbursements to critical access hospitals.”

When hospitals do not get prompt payments, Robey said, it is “very harmful to the bottom line and cash flow” for those with low margins and low patient volume.

Payment, prior authorization improvement needed

The Medicare Payment Advisory Commission noted in a report released in December that hospital margins in 2022 hit an all-time low and recommended Medicare payments to hospitals increase, which Robey said would be a step in the right direction. 

The CMS earlier this year issued a final rule on prior authorization to require MA plans, Medicaid and other public health insurance programs to respond more promptly to prior authorization requests and provide specific reasons if services are denied. The AHA wants additional action to streamline and improve the rule.  

Shannon Wu, the AHA’s senior associate director of payment policy, said 2024 Medicare payment regulations prevent MA plans from denying coverage of services that traditional Medicare covers, enhance behavioral health and tighten MA marketing rules. The AHA is currently looking at how plans are complying with the new rules, and Wu said hospitals are encouraged to report their experiences. 

Making the case to lawmakers

The likelihood of getting major health care legislation passed in a presidential election year is slim, and Pollack noted there is no consensus in either the Republican or Democratic party on the future vision for health care in the US. But Pollack urged rural hospitals to question political candidates in their area about their positions on issues such as health care workforce shortages, protecting health care workers from violence and relief to small and rural hospitals. 

“We can create an echo chamber and I think it can make a real difference in creating a political climate that is more sympathetic to our concerns,” Pollack said.

The AHA does not take positions on presidential politics but has created the “We Care, We Vote” initiative that provides resources for hospitals to prepare for the election and learn about issues.


Take advantage of SmartBrief’s FREE email newsletters for health care leaders, which are among the company’s more than 250 industry-focused publications.