Why This Texas Doctor Dumped His Medicare Advantage Plan Contracts

Bryan Johnson, MD, an internal medicine physician in Frisco, Texas, has tried hard over the past 3 years to drop all of his practice’s Medicare Advantage (MA) contracts, dropping the percentage of MA patients from 30% or 40% of his practice to 5%.

As the percentage of Medicare beneficiaries enrolled in MA plans has mushroomed — from 24% in 2010 to 54% in 2026 — why is Johnson’s practice bucking the trend?

Because treating patients enrolled in MA plans costs a lot more than what the plans pay the two doctors and a PA in his practice, Johnson told MedPage Today. He also dislikes the tactics plans use to transfer beneficiaries out of fee-for-service Medicare.

“They are just horrible plans, in my opinion,” he said. “We try to avoid them as much as possible because of our experience with them over the years.”

For starters, some of the plans have been automatically downcoding a level 4 or 5 visit to a level 3, meaning that the amount his practice receives will be as much as 25% of the claim submitted. “I’d spend time with the patient, coordinate their care, we do a follow-up, get them to a subspecialist if necessary. All that work and they automatically downcode it,” he said. “It’s a significant amount of lost revenue.”

And it gets worse. When the lower payment comes through, “we see the discrepancy, so we send a letter and fight, and it may take 6 months to get reimbursed. I have my staff investing at least 6 hours just to get my claim. It could be hundreds of dollars in cost just getting the amount from the insurance company if we can get it at all.”

“We send a letter. The company says, ‘We never got the letter,’ so we send it again. Then they want the medical records to justify the code. So we send that. And then they say, ‘Oh, we never got the medical records.’ So we send them again. We’re always fighting for our money and that’s where the expense comes in.”

Then, that’s what happened to his own mother-in-law, who has cognitive issues. She lives in a residence facility with her husband. One day, she got a phone call from an insurance agent who transferred her from traditional Medicare to an MA plan while on the phone.

“She thought she was getting a good deal so he did a verbal transfer. There were no documents. No papers were signed. And then she started getting bills for services. My wife and her sister were saying, ‘Wait, you’re not part of this plan!'”

His sister-in-law called the insurer to demand she be switched back to traditional Medicare and the supplemental plan she had as a retired teacher. But a representative declined, saying she had okayed this transfer on the phone.

“But my sister-in-law said, ‘No, you’re taking advantage of her. She has dementia. And if this isn’t corrected within 3 days, I’m going to file a complaint of elder abuse,'” Johnson told MedPage Today. “The next day she was back on traditional Medicare.”

She also had her previous retirement health benefits reinstated, said Johnson, who also is a Texas delegate to the American Medical Association.

Another issue is the surprise co-payments that beneficiaries in high-deductible MA plans learn they have to pay, Johnson continued. Many plans do not consider simple procedures, like cleaning out ear wax, a covered service. So the patient has to pay the full cost.

“They don’t understand they have an extremely high deductible and come to me in tears. ‘No doc, this isn’t right. Why are you doing this to us?’ And we just have to say, ‘This is the plan you have.'”

His practice, which he founded 26 years ago, has created an educational program that helps patients understand what they are getting with an MA plan. “Often, they trust the vendor or agent and they go ahead and sign up. And then they come back and say, ‘I wish I didn’t make that mistake.’ It’s so horrible to do that to people who are so vulnerable.”

Making a referral to a specialist — an orthopedic surgeon, for example — for a patient with MA is often another nightmare, Johnson said, costing the practice about $30 per case to get the MA plan’s approval.

But as happens all too often, a patient goes home and talks with a family member or friend who recommends a different surgeon. “With Medicare Advantage plans, if I have to cancel that referral and write a new referral — well you can’t cancel it online. You have to call and be on hold for 35 minutes — 35 minutes — and physically talk with someone to get that referral cancelled and then do the whole process again to refer to the new physician.”

And then, as sometimes happens, the new surgeon is not in network. So the process has to start all over again.

Even though some MA plans issue bonuses to practices that meet savings targets, which is nice, Johnson calculated that the cost of fighting to get basic payments is a much higher amount.

A lot of physicians just don’t realize that, he said. “It’s a very inefficient system.”

Please enable JavaScript to view the comments powered by Disqus.