The Kaiser Family Foundation (KFF) annually publishes its Medicare Advantage First Look series, which highlights that many U.S. counties have limited or no contracted Medicare Advantage Organizations (MAOs). Since 2023, Becker’s Hospital Review has regularly updated an article detailing hospital terminations of MA contracts. Whether hospitals were never contracted with certain MAOs or had contracts terminated, they are classified as “non-contracted.”
Non-contracted providers, including those serving Medicare beneficiaries through MAOs, Cost plans, and PACE organizations, are legally entitled to receive payment for Part A and Part B services at least equal to what would be paid under Original Medicare. This requirement was reaffirmed by CMS in a December 20, 2022 letter to all MAOs, following the Supreme Court's ruling that the ASP-22.5% payment formula used to reimburse 340B hospitals from 2018 to 2022 was illegal.
For 340B hospitals that were non-contracted between 2018 and 2022, it is widely believed they were underpaid for outpatient drugs by MAOs compared to Original Medicare reimbursement, which may be considered unlawful.
However, the KFF source data does not specify which counties have no MA contracts, and the Becker’s Hospital Review article indicates that there is limited data available regarding which hospitals are non-contracted with specific MA plans.
If your hospital was non-contracted with an MA plan between 2018 and 2022, we encourage you to contact GDS for a complimentary estimate of potential underpayments. GDS is currently quantifying underpayment amounts for many clients and assisting them with strategies for recovering lost revenue based on the actions taken by other organizations.
