Patients in the wrong Medicare Advantage plan are quietly hurting your practice's revenue

Brenda sits in her office lost in thought. She's seen all the things her colleagues were talking about in this morning's quality meeting. She's counseled her Medicare patients against stretching their medication because they are unaffordable. She knows patients whose plans are designed for their chronic conditions, and several who might benefit if they only knew about it. On top of that she keeps hearing that two of the Medicare Advantage plans are withdrawing from the area, so she'll send out the emails, but she knows she doesn't have the entire picture and will face more bad debt next year.

We think of coverage problems as patient problems, but some of the cost lands on practices like Brenda's. According to Kodiak Solutions, "Delays in adjudication, increased rework from denials, and more complex cost-sharing structures create uncertainty for patients about what they owe and when." Medicare Advantage in general may always have higher delays, denials and administrative work, but educated patients in plans that fit them reduce friction for everyone.

Similarly, payer rejections and abandonment due to high copays result in nearly a quarter of prescriptions given to Medicare beneficiaries going unfilled, according to IQVIA. According to the USC Schaeffer Center, the cost-share problem is getting worse, with the average Medicare Advantage drug plan deductible nearly quadrupling in a single year. Unfilled medications can lead to worsening conditions, emergency department visits and increased overall cost. Some of the conditions mentioned — diabetes, cardiovascular disease and COPD — are exactly the type of chronic conditions some Medicare Advantage plans manage by prioritizing the drugs that those patients need. Drug adherence affects quality scores and downstream costs, both of which affect Brenda's bottom line.

Plan exits and network disruptions present a different level of pain for Brenda. So far in 2026, at least 23 health systems have cut ties with certain Medicare Advantage plans, forcing their patients to choose between their doctors and their plan. As insurers discontinue plans, up to 1 in 10 Medicare Advantage enrollees now face forced disenrollment this year. This trend has accelerated enough that state insurance commissioners are calling on CMS to create new Special Enrollment Periods to deal with it, giving patients a chance to switch plans mid-year. Not only might Brenda's patients not have coverage for their doctors and/or their drugs, they could miss their best opportunity to fix the problem. Many of her patients could switch before January; they just don't know it.

Brenda knows patients in all these situations, but not all of them. Every now and again she gives out the number for a local agent and wishes them well. Her system knows there are actually 120 patients who could be on formularies better matched to their drugs, 35 of whom could switch this month. The system, in fact, knows all the patients whose conditions or health care subsidies qualify them for plans that would suit them better, all who will be affected by the new contracting changes next month, and all the patients who need advice that they may not be getting. It could deliver this information to trusted advisors with appropriate guidance immediately, today. But it doesn't.

Rather than a piecemeal approach, Brenda could review a list of everyone at her practice who could benefit from good advice from a trusted source. She could set up a referral for them just like she would to a social worker or other community resource, through her system, compliantly, with consent captured, recorded and reportable. Instead of telling her quality committee all the problems the practice faces, she could report what is being done about it.

Practice managers are told to clean up bad debt as early in the revenue cycle as possible. Quality managers are told to address medication problems when they notice them. It's possible to head off these problems before the first missed dose or unpaid balance, and the importance of doing so is increasingly evident. The data is in the room. Use it.

Scott Woods is the founder of Patient Coverage Connect, which alerts medical practices to Medicare coverage mismatches identified from clinical data and connects patients to vetted, licensed advisors. Click here for more details.