by Lilibeth Santiago, Founder of LS Consulting Services LLC
If, like me, you have been in healthcare a while, you know that managing Medicare
Advantage (MA) patients is no longer a simple administrative task — it’s a
strategic, operational, and financial responsibility that directly impacts a
practice’s revenue, quality scores, and patient outcomes. Yet many practices
still rely on outdated workflows that simply don’t match the complexity of MA
populations. After years of working with primary care groups, specialists, and
value‑based organizations, I’ve seen the same operational mistakes repeated
across practices of all sizes. These mistakes are costly — not just in dollars,
but in patient trust, compliance risk, and staff burnout. Here are the top
operational pitfalls practices face with MA patients — and what you can do to
fix them.
1. Failing to close care gaps promptly!
MA plans are built on proactive care. But many practices still treat care gaps as “optional reminders” instead of required actions. If you are relying on information that is claim-based, you're likely falling behind. Claim-based data is delayed by 30 and sometimes 90 days, depending on the payor. That means 3 months before you even know what your patient needs! Create your own source of data if you have to wait on claim-based data. The NCQA and payor websites are great sources if you're not sure what's needed based on age group. Work with your electronic health record (eHR) to optimize your access and structure a process to tackle as many of those gaps from the very first office visit of the year. As an operational goal, you should be aiming to reach 60% of all your care gaps by the end of the 1st quarter of the year. I know what you're thinking! That's crazy! Trust me, work hard the first few months of the year, and you'll see the benefit at the end!
If you can ensure 80% of your care gaps are covered by the end of your 2nd quarter, you'll be in a very good place to reach 100% before the end of the year. Many practices fail to meet their goals because they wait until later in the year, and as I'm sure you've noticed, the summer months are unpredictable for medical practices, and the fall and holiday season, forget it!
2. Poor Referral Management and Follow-Through
Let me tell you why this is an issue! You can't properly manage a patient if you don't close the loop on the care they receive outside of your practice. That means ensuring they are seeing the specialists and when they do, that you are following those specialists' recommendations. I can't begin to tell you the number of patients referred, but never make it to the specialist's office, and you never know about it until their condition has worsened. Needless to say, there are the ones that do make it, but the PCP never knows the outcome of it. This leads to fragmented care, and it can be detrimental to the efforts you're making for your patients.
3. Inadequate Documentation for Risk Adjustment (HCC Coding) - Here's something to remember about MA patients: they are complex! You know it, I know it, we all know it! But do we document it? Nope. Let me give you an illustration, you know when you ask your patients if they have any chronic conditions and they tell you, no? Then you ask, Are you on any medications and they tell you they're on Metformin, Lisinopril, Simvastatin, and 20 other meds. Well, this is the equivalent! We have patients on many medications, but medical history? Empty. The lab report shows kidney failure, but medical history? Empty. Document. Document. Document.
If you are treating for it, get paid for it! You can't if you haven't documented it! I know you're tired of seeing that patient every 3 months, but have you documented the conditions this year? Diagnoses have to be reassessed annually! This is why an annual wellness visit in the first few months of the year is ideal: to provide a structured pre‑visit workflow and provider education — not just coding audits after the fact.
4. Inefficient Front‑Office Workflows I know what you're thinking: finally, it's not all on the clinician! You're right, it starts at the front. With clear SOPs, staff training, and workflow redesign, the practice can facilitate things for the clinician and the patient to be successful.
5. Lack of Cultural Competence
I know I'm preaching to the choir, but I don't have to remind you that no two offices are alike, even if you operate in the same city. The patients you serve require different services, resources, and competencies to serve them. Know your patients! Find out what they need and how to best serve them. For some, it will mean satisfying their transportation needs so they can be in compliance with their treatment plan; for others, it will mean taking care of their emotional needs first. Again, you know your patients best!
6. Not Leveraging Preventive Care Opportunities
When it comes to managing MA patients, the key will be in preventing rather than reacting. Missed annual wellness visits or incomplete/rushed ones can lead to loss of revenue, missed opportunities in identifying chronic conditions, or existing ones exacerbating. These patients' conditions can change and do so fast; thus, seeing them only once a year, no matter how healthy they may seem to you now, may not be ideal!
For more information on our consulting services visit www.lsconsultingservices.net or call us 689-224-9789 lsantiago@lsconsultingservices.net
MA plans are built on proactive care. But many practices still treat care gaps as “optional reminders” instead of required actions. If you are relying on information that is claim-based, you're likely falling behind. Claim-based data is delayed by 30 and sometimes 90 days, depending on the payor. That means 3 months before you even know what your patient needs! Create your own source of data if you have to wait on claim-based data. The NCQA and payor websites are great sources if you're not sure what's needed based on age group. Work with your electronic health record (eHR) to optimize your access and structure a process to tackle as many of those gaps from the very first office visit of the year. As an operational goal, you should be aiming to reach 60% of all your care gaps by the end of the 1st quarter of the year. I know what you're thinking! That's crazy! Trust me, work hard the first few months of the year, and you'll see the benefit at the end!
If you can ensure 80% of your care gaps are covered by the end of your 2nd quarter, you'll be in a very good place to reach 100% before the end of the year. Many practices fail to meet their goals because they wait until later in the year, and as I'm sure you've noticed, the summer months are unpredictable for medical practices, and the fall and holiday season, forget it!
2. Poor Referral Management and Follow-Through
Let me tell you why this is an issue! You can't properly manage a patient if you don't close the loop on the care they receive outside of your practice. That means ensuring they are seeing the specialists and when they do, that you are following those specialists' recommendations. I can't begin to tell you the number of patients referred, but never make it to the specialist's office, and you never know about it until their condition has worsened. Needless to say, there are the ones that do make it, but the PCP never knows the outcome of it. This leads to fragmented care, and it can be detrimental to the efforts you're making for your patients.
3. Inadequate Documentation for Risk Adjustment (HCC Coding) - Here's something to remember about MA patients: they are complex! You know it, I know it, we all know it! But do we document it? Nope. Let me give you an illustration, you know when you ask your patients if they have any chronic conditions and they tell you, no? Then you ask, Are you on any medications and they tell you they're on Metformin, Lisinopril, Simvastatin, and 20 other meds. Well, this is the equivalent! We have patients on many medications, but medical history? Empty. The lab report shows kidney failure, but medical history? Empty. Document. Document. Document.
If you are treating for it, get paid for it! You can't if you haven't documented it! I know you're tired of seeing that patient every 3 months, but have you documented the conditions this year? Diagnoses have to be reassessed annually! This is why an annual wellness visit in the first few months of the year is ideal: to provide a structured pre‑visit workflow and provider education — not just coding audits after the fact.
4. Inefficient Front‑Office Workflows I know what you're thinking: finally, it's not all on the clinician! You're right, it starts at the front. With clear SOPs, staff training, and workflow redesign, the practice can facilitate things for the clinician and the patient to be successful.
5. Lack of Cultural Competence
I know I'm preaching to the choir, but I don't have to remind you that no two offices are alike, even if you operate in the same city. The patients you serve require different services, resources, and competencies to serve them. Know your patients! Find out what they need and how to best serve them. For some, it will mean satisfying their transportation needs so they can be in compliance with their treatment plan; for others, it will mean taking care of their emotional needs first. Again, you know your patients best!
6. Not Leveraging Preventive Care Opportunities
When it comes to managing MA patients, the key will be in preventing rather than reacting. Missed annual wellness visits or incomplete/rushed ones can lead to loss of revenue, missed opportunities in identifying chronic conditions, or existing ones exacerbating. These patients' conditions can change and do so fast; thus, seeing them only once a year, no matter how healthy they may seem to you now, may not be ideal!
For more information on our consulting services visit www.lsconsultingservices.net or call us 689-224-9789 lsantiago@lsconsultingservices.net
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