RISE Radio

Episode 25: The political shift: How Medicare Advantage plans can navigate coming changes

• Ilene MacDonald

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The Medicare Advantage (MA) landscape is shifting dramatically. With over half of all Medicare beneficiaries now enrolled in MA plans, the program faces unprecedented scrutiny from lawmakers, regulators, and beneficiaries themselves. During this 40-minute podcast, MA policy experts Carrie Graham and Neil Patil dissect the changing political and regulatory climate surrounding MA and offer crucial insights for health plans navigating these turbulent waters. They explore how the Trump administration is approaching MA reform through payment adjustments, increased oversight, and technological innovation.

Graham and Patil delve into hot-button issues driving the reform conversation: prior authorization practices that frustrate both providers and patients, marketing tactics that have drawn Department of Justice attention, and the accuracy of provider directories that directly impact beneficiary access to care. They discuss key bipartisan legislative proposals gaining traction, including the No UPCODE Act and the Improving Seniors' Timely Access to Care Act.

Want to learn more? Graham and Patil will speak at RISE West 2025, the Medicare Advantage senior leadership event of the year, August 25-27, at Paris Las Vegas. Also check out additional information from the Medicare Policy Initiative blog posts, publications, tools, and resources, including a compendium of Medicare Advantage policies and a comparison tool of legislation that's been rumored to be included in a potential end-of-the-year legislative package (the Improving Seniors Access to Timely Care Act) and CMS regulations.

Carrie Graham, Ph.D., is a research professor and the director of the Medicare Policy Initiative at Georgetown University’s Center on Health Insurance Reform (CHIR), where she oversees a portfolio of policy analysis, research, and technical assistance for policymakers on Medicare Advantage and original Medicare. Previously she was the director of aging and disability policy at the Center for Health Care Strategies. She also holds an adjunct professor appointment at the University of California, San Francisco, Institute for Health and Aging.

Neil Patil, MPP, is a senior fellow and the policy director at the Medicare Policy Initiative at CHIR, where he conducts policy analysis and provides technical assistance to policymakers on Medicare Advantage issues. Prior to joining CHIR, he was a senior analyst at the Centers for Medicare & Medicaid Services Office of Legislation, where he provided technical assistance to Congress on issues related to Medicare Advantage and the Medicare Drug Price Negotiation Program. In this role, he served as the lead analyst on Medicare Advantage issues. 

Ilene MacDonald:

Hello and welcome to the latest episode of RISE Radio. I'm Ilene MacDonald, the Editorial Director at RISE, and today we will be discussing the changing Medicare Advantage political landscape and how to navigate those changes. Joining me for the discussion are Carrie Graham and

Ilene MacDonald:

Neil Patil, both experts in Medicare Advantage policy. Dr Graham is a research professor and the director of the Medicare Policy Initiative at Georgetown University's Center on Health Insurance Reform, or CHIR, where she oversees a portfolio of policy analysis, research and technical assistance for policymakers on Medicare Advantage and Original Medicare, and Neil is a senior fellow and the policy director at the Medicare Policy Initiative at CHIR, where he conducts policy analysis and provides technical assistance to policymakers on the Medicare Advantage issues. Both are going to be speakers at Rise West 2025, which will be held later this month in Las Vegas for two sessions that focus on Medicare Advantage's political landscape, so I'm thrilled to welcome you both to the podcast. Welcome and to start, I wonder if you both and maybe Neil, you could start offer some of your thoughts on the current state of Medicare Advantage.

Neil Patil:

Sure, yeah, I'm happy to, and thank you so much for having us. We're really excited to have this conversation today and to be featured at RISE West. So you know, I think, to kind of start this off, you know it's really important to note that last year the United States spent about $910 billion on Medicare overall. That's about 13% of all US spending, and Medicare beneficiaries are just increasingly choosing Medicare Advantage. You know, now at this point, over half of Medicare beneficiaries are enrolled in MA and you know there have just been a wide variety of research organizations, the Medicare Payment Advisory Commission and others out there, who have provided a lot of evidence that the federal government right now pays these MA plans considerably more than they do for the same beneficiaries under traditional Medicare. So you know, I mean even just to give you an example here the Medicare Payment Advisory Commission, or MedPAC, estimated that CMS will pay 20% more for MA enrollees compared to traditional Medicare and that really totals about $84 billion. So you know this is a really big issue because we do want to ensure sustainability of the Medicare program and you know seniors and people with disabilities really do rely on this program.

Neil Patil:

So you know, I think, to answer your question, what is the current state of Medicare Advantage? Well, right now there is a growing bipartisan group of policymakers who are really supporting ways to reduce Medicare spending, and specifically Medicare Advantage spending, while finding ways to maintain this current level and quality of benefits. You know, Medicare Advantage enrollees do really love having their supplemental benefits, having things like dental, vision, hearing and other benefits that traditional Medicare does not cover. So really, this is a bit of a conversation right now in this country about sustaining the program for future generations but also maintaining these really great benefits. And as far as this administration goes, we've really noticed that this administration has been all about technology and really really supportive of trying to find ways to use enhanced technology and artificial intelligence as a way to solve problems and innovate the program and, again, find ways to make this program sustainable for future generations.

Ilene MacDonald:

Thank you. Carrie, did you want to add anything to Neil's perspective?

Carrie Graham:

I think Neil covered it really well.

Carrie Graham:

I would just say that, you know, back in the day when we just had traditional Medicare, it's paid on a fee-for-service basis and so there were a lot of problems with that.

Carrie Graham:

It motivated and incentivized health care providers to provide treatments that were more expensive, to do less preventative care and really the promise of Medicare Advantage, using utilization management, managed care tactics, was to reduce costs, and I do think the Medicare Advantage program, with things like it's out-of-pocket caps for beneficiary spending and things like that, have really, on the one hand, fulfilled the promise of making it a little cheaper for, or at least the costs are more predictable for, beneficiaries.

Carrie Graham:

But it really is surprising and many people think managed care is cheaper and it's just, the evidence is showing it's not and, as Neil said, I do think there's bipartisan support for correcting that a bit and really having some awareness out there. This administration is about cutting federal spending and I do think that, even though Medicare Advantage was not targeted in the reconciliation bill, where Medicaid and a lot of other programs were targeted, I do think that there is some understanding that this is a big, if the overpayment research is correct, which it seems like it's becoming understood that it is, that there's going to be some interest in correcting that, and we're already seeing that on the Hill.

Ilene MacDonald:

I think today I read in Health Affairs a very similar study or a research letter that indeed it is costing so much more than originally intended .

Carrie Graham:

And it's true. There's lots of different ways to calculate how much things cost in the health care world. This is why we have health economists. It can be really, really complicated, but when you put all the research together from nonpartisan sources, from government oversight and from academic researchers, I think it's at this point, understood that we are paying, taxpayers are paying about 20% more for similar beneficiaries in Medicare Advantage and that's just not what the that was not the promise of the program. And there are areas. There are certainly many, many areas that could be fixed.

Ilene MacDonald:

In your view, what would be the best way to sort of fixate on those areas that need to be fixed, and is the administration sort of from what you can see working towards those kind of changes and concerns?

Carrie Graham:

Yes, absolutely. I mean I think there's not one. The thing about it is there's not one fix. You know there's certainly and Neil can get into this with the actual bills and policy proposals that are out there and being considered and have by many having bipartisan support. But it's, you know, risk adjustment and payment is one area. Another area that you're seeing all over the news and has become a very public outcry around prior authorization and delays in treatment. I think that you know that's something that many people want to fix.

Carrie Graham:

There's a lot of issues that come down to transparency for beneficiaries. Because when we think about this program it was it used to be called Medicare Choice Program. It was really designed to say beneficiaries should have a choice of all these different kinds of care and all these different packages. But when we get down to it and we just wrote a brief on this there are so many areas that aren't transparent for beneficiaries.

Carrie Graham:

You know the quality scores don't reflect the quality scores of your plan. They reflect the quality scores of it could be dozens of plans that are in, you know, a contract that the government has with the company that owns the plans. You know there's a lot of things that are just not transparent for the beneficiaries when they're choosing, and so I think that a lot of the fixes things like being more clear about supplemental benefits you know, what do you actually get in your supplemental benefits? Are you actually qualified for those? There's just many, many things that you could take the tack of beneficiary transparency and fix a lot of these things as well.

Neil Patil:

Yeah, no, that's exactly everything that Carrie has said is exactly right. And, you know, Ilene, I also wanted to kind of talk about a little bit about what this administration has done on, you know, on these issues here, and really I think I can kind of put this into three main buckets. There's payment, there's oversight, and then technology. So first I'll start with payment here. First I'll start with payment here. You know, earlier this year in April, the Centers for Medicare and Medicaid Services, the agency that's responsible for overseeing Medicare, they put out the annual rate announcement, which includes the payment policies for the upcoming year 2026. And in that the rate announcement is actually projected to increase Medicare Advantage payment by about, you know, 5%, and you know so we are seeing, actually that those policies, every year we are seeing increases in payment and some of that comes from increased utilization or the increase of health care costs. But, as you know, as lawmakers are thinking about this, well, that's about twenty five billion dollars of increased payments, and you know so. So we do also need to think about sustainability of the program and whether payments are, you know, properly going to MA plans. So you know, ma plans that are caring for sick or patients who need more care should be paid more. But you know there have been discussions about whether MA plans may be upcoding or trying to, you know, game the system by producing more diagnoses that are used for increased payment.

Neil Patil:

After that I'll talk a little bit about oversight. So I think there haven't been a ton of new policies around oversight. The one big thing that I wanted to mention is the Biden administration had proposed the 2026 Medicare Advantage annual rule, which is just the policy, the kind of more, the policies outside of payment essentially and in that rule they propose to require that the use of artificial intelligence in prior authorization basically has to make sure that care is still provided equitably. Authorization basically has to make sure that care is still provided equitably. We'll talk a little bit more about this later, but I think a big thing is that when the Trump administration came in and they finalized that rule, they did not finalize that policy, but they still did know that they are really interested in looking at artificial intelligence and thinking a little bit more about what that means. And I think this really segue ways to this discussion about technology, because not only is the administration, you know, thinking about artificial intelligence, but they're talking about ways to use enhanced technology to, you know, essentially try to improve the program.

Neil Patil:

So in May actually, CMS announced that plans to really expand risk adjustment data validation audits and these are the audits that are primarily used to recover overpayments made to MA plans. So this is really when you know essentially how this works. For my time at CMS, my understanding is, you know, we actually have teams of medical coders that will go through samples of the diagnoses that MA plans submit to CMS for payment and just ensure that all of those diagnoses are actually reported in the medical records and when they're not, the payments made for those diagnoses are recouped from those plans. So it's really interesting because, you know, CMS has historically just been auditing kind of small samples of MA contracts, which are really kind of a group of MA plans under an MA organization. So year after year they've been auditing anywhere from about 30 to 60 MA contracts out of about, you know, 550 to 700 contracts.

Neil Patil:

And these plans are really really significant because CMS is going to invest in new technology and artificial intelligence to review medical records and flag these undiagnosed , unsupported diagnoses. So they're actually planning to now audit, you know, from 60 MA contracts to all 550 of them and you know, planning to audit anywhere from 35 records now to almost 200 of these health records per year and that, of course, is going to come. You know it's a lot of questions about how that can be done, beginning September 1st, which is only a few weeks away. But also, CMS said you know they have plans to seriously increase the number of coders. They have from about 40 to 2000. So you know, when we talk about technology and what CMS is doing in the oversight realm, this is a huge, huge announcement and you know we're definitely going to be keeping an eye on it.

Ilene MacDonald:

You mentioned and Carrie mentioned too, some of the concerns with, and there has been a lot of negative press on the prior authorization, on the oversight, authorization we talked a little bit what CMS is doing, but what lawmakers might be thinking to do next in these issues?

Carrie Graham:

I would just say that there's three or four main things that have gotten a lot of press and that people don't really like about the MA program. They're really beginning to criticize the MA program, whether it's newspaper articles or social media accounts. You know, one of those is prior authorization, as we discussed and there is are social media accounts, where doctors make videos record themselves on the phone with an MA plan their patient getting denied care that they think is really really medically appropriate.

Carrie Graham:

The other thing that the administration likes but makes people really uncomfortable is the use of AI. So you know it's just people, don't? It just makes people feel like what? My care is being denied by a computer, you know. So there's a lot of discomfort around AI because it's it's a bit of a black box for people, and so, on the one hand, you can use AI to make as much, you know, manipulate things and make as much money as you can as a company. On the other hand, you can use it to improve care. So we really do see that there's trying to. You know this administration is trying to think about ways to use it to improve care, and you know the third thing that we've already talked about is that it's just not fulfilling its promise to be less expensive for the federal government, and with with such a big big price tag, small changes could save American taxpayers a lot of money, and I'll let Neil get into some specifics about what's actually happening on the Hill.

Neil Patil:

We are constantly in communication with folks on the Hill and you know from the legislative front. I guess one of the first things I want to talk about is the reconciliation bill, the One Big Beautiful Bill Act. You know, for a while there was a lot of discussion of a Medicare Advantage policy being included in that reconciliation bill, but it ultimately wasn't included, and that's a bill called the No UPCODE Act. So when we're talking about these diagnoses that are reported to CMS, one of the things that folks have and this has come from beneficiary groups, providers and also places like the Office of Inspector General and the Government Accountability Office, OIG and GAO respectively, you know is that some of these plans may be using different tools, such as the use of chart reviews, where they're digging back through some of these charts and finding diagnoses, and also these in-home health risk assessments, where they might be sending, a clinician to a beneficiary's home and essentially trying to potentially find diagnoses. And I think one of the biggest concerns is that you know there's a lot of diagnoses that are reported from those tools, but we're not necessarily, we're not sure, at least, if we're seeing care for those diagnoses being reported. So you know, what this bill is really trying to do is basically say, diagnoses from these different places won't be used for risk adjustment unless you can essentially prove that the enrollee is receiving care for that. And I think this is certainly one of the bills that is, you know, still on the table, could be included in another legislative vehicle and has been discussed for many years as potentially being included. In fact, recently, I just want to point, the AARP endorsed this legislation and called it a common sense solution to protect older Americans and strengthen oversight. So that's certainly one major piece of legislation we're looking at.

Neil Patil:

But the other one I want to talk about is the Improving Seniors' Timely Access to Care Act. So this is and has been the major bipartisan prior authorization legislation for years and years and years now. So you know, just to give you a couple of highlights of the bill, it would, you know, require electronic prior authorization processes, require real-time decisions for some of these prior authorization requests and also requires a lot of new reporting requirements at the plan level. You know, things like what's the percent of prior authorizations that are actually denied or approved, or approved after appeal? So really it's, you know, both a transparency bill, but it's also trying to reduce provider burden and ensure that prior authorization is, you know, being used appropriately and not just unilaterally to deny care.

Neil Patil:

And this has been one that has been talked about and moved quite a bit through Congress. It actually passed the House in 2022. And there's certainly a lot of discussion of this one as a potential piece of legislation. But, you know, aside from that, I think there's still chatter around issues such as increasing the accuracy of provider directories, you know, making sure that the beneficiary is looking at their plan's provider directory, it's accurate and they can actually, you know, receive care from some of the providers listed there. And on top of that, we are hearing rumblings of a potential artificial intelligence bill coming out. This happened during the Ways and Means Committee's recent hearing on Medicare Advantage, where Representative Chu, Judy Chu from California mentioned, potentially coming out with an artificial intelligence bill. So you know, we're keeping an eye out to see what that might look like, but you know there's certainly a lot of pieces of legislation moving around on the Hill in this space.

Ilene MacDonald:

There really is, and I wonder if I can get your thoughts sort of related to the prior authorization in MA. CMS is piloting now, or planning to in September, a program in Medicare to use AI for prior authorization, which surprised me that, given all the concerns with prior authorization in MA. What are your thoughts on that and what this might mean to the Medicare program in general and possibly to MA?

Carrie Graham:

I'll just preface by saying it was surprising that you know the administration would come out with this, given just the uproar in public opinion around the uses of prior authorization in MA and so to impose that kind of prior authorization it's like the thing people hate most about MA. Putting it in, traditional fee-for-service Medicare seemed a little as you said, it was a bit jarring and surprising that this might not be the time to do that. On the other hand, the list of services that they will be doing utilization management on are ones that are typically that get denied a lot and have, you know, kind of a history of maybe being low value care care that you know isn't very effective and costs a lot of money. So you know it was strange timing to do it then, and but it will be interesting to see, and I'll hand it off to Neil for more specifics. .

Neil Patil:

I think what you covered is exactly right, Carrie. And you know, I guess let's talk a little bit about why do we have prior authorization? And you know it's a tool in Medicare Advantage and it should be used to really incentivize high-value care and avoid low-value care. And so you know, as far as the rationale for CMS I think that's kind of what CMS is thinking is you know, let's also try to ensure that traditional Medicare beneficiaries are also receiving high-value care and avoiding low-value care such as, you know, emergency department visits for non-emergencies, things like that.

Neil Patil:

So you know, I think some of the big, big considerations for this and kind of questions that we want to, you know, make sure is essentially the lessons learned from how this has happened in Medicare Advantage.

Neil Patil:

We want to make sure it's not being used inappropriately to unilaterally deny care or that it's not going to result in disruptions in care. You know, right now, under Medicare Advantage, there's rules for transition periods that prohibit prior authorizations when new MA enrollees are undergoing active treatment or MA enrollees switch plans, things like that. And you know, we want to make sure, you know, or I guess we have questions about whether those same protections that are in place in Medicare Advantage will now apply to traditional Medicare. There's time periods, specified time frames for when plans have to give a decision for a prior authorization, and again we're kind of wondering is that going to apply as well to this new model? So I think for us there's just a lot of lessons learned from Medicare Advantage and a lot of questions about whether all of these new rules that CMS has put in place over the past few years will apply to this new wiser model.

Ilene MacDonald:

Given everything we've talked about so far, what do you think health plans and a lot of our listeners are Medicare Advantage plans, what should they be thinking about in the wake of all these changes what lawmakers are thinking, but also what actual administration changes have been made?.

Carrie Graham:

And again I'll just start out. I think there's been a tipping point in public opinion. I think there's some frustration with some behavior of certain plans not all plans. There's, you know, been some frustration around things like marketing, you know, not being super clear or transparent in marketing, having agents and brokers who, you know, legally, are supposed to look at a person's situation and direct them to the plan that's best for them, but they are, you know, getting paid by certain plans, and we know that the Department of Justice has just joined a whistleblower lawsuit alleging that certain plans are giving big kickbacks that are illegal to brokers for putting people, you know, directing people into plans that maybe aren't right for them. So all of this is coming out and If I were in charge of a MA plan, I think right now would be a great time to be thinking about beneficiary perspective and beneficiary transparency.

Carrie Graham:

There are certain kind of data that need to be reported for government oversight, but there also are things that need to be reported and clear for beneficiaries to feel some agency that they are able to pick the plan that's right for them. That when they are looking for plans, they can look at a provider directory and actually know whether that doc, the doc, maybe it's their doctor and they see the provider directory, their doctor's in the plan. That seems fine, but then later they find out the doctor's not actually in the plan or taking patients. So there's so many things that I think plans can do to really center beneficiary experience and, you know, just get the reputation back a little bit in terms of making sure that beneficiaries are getting the care that's prescribed by doctors. In terms of prior authorization, you know there's certain things that are just covered by Medicare and they are Medicare covered services, but MA plans can use internal coverage criteria to deny that if it seems like it's not warranted in that case. And so more transparency about what are our internal coverage criteria for this.

Carrie Graham:

When you're advertising, you do supplemental benefits. Maybe one of your supplemental benefits is transportation. Is it transportation anywhere? Is it two rides a year? You know what is it really? So just being, I think the first thing I would do is just try to be a lot more transparent with beneficiaries and I think people just feel out of control. I think they feel like they don't have a real choice right now and things are happening with their MA plan that were not promised and were not expected, and that their trusted provider is saying they need this care and it's being denied. So I think that's one thing that plans could really do to try to turn the corner on some of this bad press.

Neil Patil:

Yeah, and I think you know I'll piggyback on what Carrie said and I'll give five specific recommendations for a health plan. The first thing that I would say is, regardless of the specific requirements for gathering data and reporting that data to CMS or to the public, continue to gather as much data and information as possible on your health plan. It's just really important to know, you know, are supplemental benefits being used? You know why might there be gaps in certain data? Are you sure about the use of prior authorization? Or why might the appeals rates be very high for prior authorization denials? You know this data and information is just going to be really, really helpful so you can ensure that you're being compliant with all of these requirements.

Neil Patil:

Number two, I would really look at the specific marketing around supplemental benefits and just be entirely clear about the scope of benefits, who qualifies, and also, again, kind of going back to the data piece is just, you know, take a look at, maybe, why the supplemental benefits are not being used as much as they could be. Third, I would really look under the hood of prior authorization requirements and processes and specifically looking under the hood of AI. You know, I know a lot of health plans and for good reason, contract these to external vendors. But, I think it's really important because the health plan is the one that's, you know, under scrutiny and CMS is looking at the health plan to really, ensure compliance even with their contracted entities. So, look under the hood of the AI that's being used or any you know organization that's doing prior authorization, and make sure that you're being compliant with all Medicare laws, regulations, national coverage determinations, every little piece of this.

Neil Patil:

Because it's going to be really important and I'm not sure if I actually was at four or five, but I'll just say the last one is just to be really, really careful about the use of agents, brokers and third-party marketing organizations. First of all, ensure that your contracts with these groups are appropriate, are compliant with MA rules, because the biggest thing is, agents, brokers and third-party marketing organizations are supposed to be impartial and are really just supposed to ensure that beneficiaries are able to find the health plan that best suits their needs. So, you know, not just your contracts, but be careful about what you're saying to agents and brokers and the things that you're telling them in meetings or even over texts or calls, because you know that that has now spurred some new lawsuits. And you know, just ensuring compliance with all of these different rules, including the False Claims Act and Medicare statute, is just really, really important right now.

Ilene MacDonald:

All true, all good tips and, Neil, maybe you can start. Given all that, what kind of oversight can MA plans expect in the upcoming year?

Neil Patil:

Yeah, well, we've already discussed these risk adjustment data validation audits, but certainly investing in these RADV audits is going to be really, really important because you want to ensure that all these diagnoses that are reported are included in t he medical record so you are not paying overpayments but on top of that know we are seeing more audits and potential lawsuits related to agents and brokers including this year, where the Department of Justice filed a complaint against the leading Medicare Advantage plan and some of the insurance broker organizations under the False Claims Act. So that's certainly another place where you know we could see potentially the DOJ filing more complaints. And then I would also say another area is probably going to be prior authorization. Now, of course, in 2023, 2024, we saw a lot of new prior authorization rules come out of CMS streamlining prior authorization, new reporting requirements. So I would just say to you know, ensure that you're being compliant with those.

Neil Patil:

Create systems now, because there likely will be oversight, and you know CMS has various oversight tools to ensure compliance with these new requirements. So you know some of those include you know, beginning next year, there's required reporting metrics for prior authorization, as well as, tracking and providing specific reasons for denials, and the biggest one is going to be implementing electronic prior authorization processes. So, ensuring that you're ready to go with that in the next year and a half, because that's going to start soon and I think we were really encouraged to see, you know, a lot of health plans come out and make commitments regarding standardizing electronic prior authorization and reducing the scope of benefits subject to prior authorization. So, I think, just continuing to do those things and just being aware that these are probably some of the major areas of oversight this year, Carrie, did you have anything to add?

Carrie Graham:

I absolutely agree with everything that Neil said. One area that pops up for me that we're beginning to hear rumblings about is marketing to veterans. . So we've seen a couple of news articles and some interest on the Hill in MA plans that are marketing products to veterans, and those veterans get most of their care from the VA so that the federal government is sort of paying twice they're paying the MA plan and they're paying for the care through the VA. So you may see some oversight or some legislation trying to prevent those practices coming up as well.

Ilene MacDonald:

Is there anything we haven't discussed, anything that you think would be important for our listeners today and those who will be attending RISE West to be thinking about in the upcoming weeks, months, year ahead?

Carrie Graham:

I think one of the things that I know Neil touched on this and I just piggyback on that about collecting data. We're beginning to see MA industry and allies make an argument about equity and making arguments that MA is better for people who are lower income, people of color, and the reasoning is is because more lower income people choose MA. So we saw at the recent hearing a witness said well, MA is now a safety net program because it's more low income people are choosing MA and I think you know, logically, a lot of people say well, that's because it can be less expensive. But if that is a argument that an MA plan is going to be making, then I think it's really important to have that data to back it up and bring the receipts really about do you actually provide better quality of care to vulnerable populations and have that research and have that documentation even if the federal government isn't requiring it right now, making sure that the supplemental benefits you offer are being distributed equitably and that you're still studying the outcomes and looking at certain vulnerable populations, especially if those arguments are going to be made that the program is better for certain vulnerable populations.

Neil Patil:

Yeah, I think I would say on one last topic, I mentioned it a little bit and I don't think it gets as much coverage as maybe it should. But I want to talk about accurate provider directories a little bit. You know there was a really, really great report that came out from the Senate Finance Committee chair at the time, now ranking member Ron Wyden of you know, releasing findings from a secret shopper study conducted by the committee staff where they essentially reviewed directories from a number of different plans and found of those, about a third of the phone numbers were either inaccurate or non-working numbers. They couldn't make appointments for about 18% of the time. So all you know, all to say and this is similar to other secret shopper studies is just, I know that plans have made a concerted effort to try to improve the accuracy of their provider directories, and this is both a plan and a provider issue. So I will say that too.

Neil Patil:

But you know, I think one of the big things is, I would say maybe, you know, we can try to think a little bit more about innovative ways, maybe even using enhanced technology, for plans to just try to make their provider director y more accurate or maybe more frequent verification, or change your contract terms a bit and require that providers you know sort of give this information. Because you know I will say there's legislation out there on this topic. It is very bipartisan and it's another one of those pieces of legislation that may be included in an end of the year package around more verification, more information being reported and on top of that, potentially also some cost-sharing remedies in there to ensure that beneficiaries are not paying out-of-network cost-sharing when the provider was inaccurately listed as in a network. So you know, I would just say, start thinking now a little bit about ways that we could innovate that process and try to improve the accuracy of these provider directories, because it's important. It's important that beneficiaries are able to, you know, get the care they need.

Ilene MacDonald:

Absolutely. I have a 91-year-old mother who's in a plan and the provider directory is key, I can say from experience to find out if they're covered. I want to thank you both for your time today. I'm so looking forward to your conversation at RISE West 2025 as well. I know I'll learn more and I thank you both.

Neil Patil:

Thank you so much for having us, Ilene and we hope you have a wonderful one.

Carrie Graham:

Thanks, Ilene, it was great to be here.