That same year, though, flaws and limitations in Medicare Advantage plans began to show as contract disputes nationwide spiked in 2023, climbing 50% over the year before, becoming an even greater share of insurance disputes, according to Healthcare Dive<\/a>. Medicare Advantage disputes made up 67% of all disagreements in 2023 compared to 57% the year before.<\/p>\n Related Story: Fresno Unified Retirees Will Have to Wait Until 2027 for New Medicare Option<\/a><\/p>\n Since then, public disagreements about insurance plans have only increased with inherent issues surrounding prior authorization, payer mix, and reimbursement rates at the center of the arguments, said Alexandra Rivera-Gonz\u00e1lez, assistant professor at UC Merced\u2019s Department of Public Health.<\/p>\n Despite being offered through private companies, significant regulations make elusive a reimbursement rate that payers and providers can agree on. Additionally, unlike standard commercial programs, Medicare Advantage doesn\u2019t have a diverse patient pool of healthy enrollees to dilute insurance payouts.<\/p>\n For regions such as the Central Valley with a provider shortage, the reimbursement problem for providers gets compounded, Rivera-Gonz\u00e1lez said.<\/p>\n \u201cHow much are they going to be paid because they\u2019re having to put in a lot more work compared to maybe other areas where that\u2019s not so much the case,\u201d Rivera-Gonz\u00e1lez said. \u201cThey\u2019re pretty much working double, triple, but getting paid the same. A lot of the negotiations fall onto that.\u201d<\/p>\n Medicare Advantage \u2014 known as Medicare Part C \u2014 has grown dramatically in recent years, enrolling now about 34 million members, or roughly half of people eligible for Medicare. Cracks in the program have begun to show, however, as insurers pull back plan availability.<\/p>\n The Centers for Medicare & Medicaid Services expects Medicare Advantage enrollment to decrease by 1 million beneficiaries this year.<\/p>\n Aetna announced in 2025 that this year the company would cut nearly 10% of its Advantage programs.<\/p>\n \u201cEach year, we assess our ability to meet the health care needs of our members and adjust our plans to ensure they can deliver an excellent and sustainable member experience,\u201d said a\u00a0 spokesperson for Aetna. \u201cFor 2026, we decided to stop offering individual Medicare Advantage plans in certain California counties, including in Fresno County.\u201d<\/p>\n UnitedHealthcare, Humana, and Cigna also announced cuts. Minnesota felt cuts hardest as nonprofit UCare announced it would make significant cuts this year.<\/p>\n Fresno County is set to lose the most Advantage plans this year among California counties with a net loss of 11 plans, according to Investopedia<\/a>.<\/p>\n Value-Based Care Incentivizes Not Taking on Sick Patients<\/p>\n Last year, Aetna switched from a fee-for-service pay model to a \u201cvalue-based care\u201d model. Aetna said the value-based model pays doctors for treatment results, not based on the number of tests or visits they do.<\/p>\n In a news release, Aetna said the model would fix many problems in health care. The insurer said by focusing on quality, doctors can lower costs for patients.<\/p>\n \u201cDoctors can focus on quality care instead of rushing through appointments,\u201d the release stated. \u201cEmployers can offer better health benefits and still manage costs.\u201d<\/p>\n In addition, the fee-for-service model has problems with questionable billing practices.<\/p>\n Kaiser Permanente made national news<\/a> after it agreed to pay $556 million to settle allegations from the U.S. Justice Department that the provider overbilled approximately $1 billion in Medicare Advantage payments from 2009 to 2018.<\/p>\n A U.S. Senate report likewise accuses UnitedHealth Group of \u201cgaming\u201d Medicare Advantage.<\/p>\n The value-based model also has drawbacks, Rivera-Gonz\u00e1lez said. Using the health of a patient as a standard for payment can be hard, especially for older populations with health needs that worsen as they age.<\/p>\n It can also incentivize physicians not taking on sicker patients because their health might not improve.<\/p>\n \u201cIf you have a patient who you know is not really going to improve, then is it worth taking that on?\u201d Rivera-Gonz\u00e1lez said. \u201cSo the value-based care model is kind of another angle as to why these disputes have grown.\u201d<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/us-ca\/wp-content\/uploads\/2026\/01\/Total-contract-disputes-and-those-involving-Medicare-Advantage-Q1-2022-Q3-2025-.jpg\")
Total contract disputes and those involving Medicare Advantage, Q1 2022 \u2013 Q3 2025 (Healthcaredive.com)
\nFresno County Hit Hardest in California in Lost MA Plans<\/p>\n
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Prior authorization determinations from KFF Health News