Friction between providers and health plans is a long-standing issue. Providers’ distrust of plans is driven by the financial and bureaucratic aspects of their relationship with frustrations around claims denials and prior authorization often topping their list of complaints. Health plan executives in turn highlight a lack of accurate and timely data sharing as a compounding issue for the relationship.¹ Nowhere is this strained relationship more evident than in the Medicare Advantage market.

Plans are facing revenue pressures in Medicare Advantage due to methodology changes regarding benchmark rates, risk-adjustment models, and Star ratings calculation. Simultaneously, they are feeling medical loss ratio (MLR) pressures as a result of a bounce back in utilization among seniors. For example, MA plans saw an 8.1% increase in per member per month (PMPM) total medical expenses from Q4 2022 to Q4 2023.²