The Secret to Your Success Here’s an example what the public is hearing about the new “step-therapy” program for Medicare Advantage, via Forbes. Tell your patients that if they don’t want their medication choices affected by step therapy, talk to their insurance agent about a plan that won’t require it. They’ll have many options and they may want to pay less if the step therapy doesn’t affect their medication choices much. Oncologists are...
Read MoreDesigned to Amaze and Enlighten! How many risk-codes are included in your patient’s capitation calculation each year. A. The top four based on revenue generated. B. the four most common. C. 4 for ages 65-74, 6 for ages 75 and above. D. Depends on why they enrolled in Medicare in the first place. E. None of the above. The startling answer below: X x x x x x x x x x...
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Mrs. Smith was livid, I had given her sister bragging rights over her and she was greatly displeased. Mrs. Smith had called the office requesting I come see her for a house call and then “went off” on my great staff when I refused. I had done one for her sister days before. Her sister was homebound from a stroke and I, new in town, saw her at home for a visit in...
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Working with a prospective client, I discovered they were taking matters into their own hands. Appalled at the potential cost of a new unfunded Medicare Advantage contract, they decided to be pro-active. They’re hiring their own home care workers. If you recall, Medicare Advantage will allow a home care worker benefit for certain beneficiaries. It is a benefit with no additional funding—and it will be administered by third parties providers who’s only...
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You may have heard that starting next year, Medicare Advantage insurers may limit the choices available for your medications. It’s called “step-therapy” and it refers to the fact that, if you need a medicine beyond the basics in each class, your doctor is going to have to get approval from the insurance company to get it. A pain for her and a pain for you. This is new in Medicare Advantage. It’s a way to...
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A tropical storm tore through Texas this past weekend. Tons of rain, some wind, widespread flooding. People in isolation. My telemedicine provider put me on “alert.” I took almost 150 calls over three days. Most were simple, some involved some taxing problems—especially since the pharmacies were nearly all closed. One was a woman in labor panicking and not knowing what to do. I was able to care for...
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I was speaking with an ACO executive last month about the challenges of bringing specialists on-board to the “value-based” manner of thinking. “When we tell them they have to shave another $500 off of every episode of care, they get angry, then abusive and then they tune us out.” I bet! When I was first figuring out how our total-risk Medicare Advantage contract worked, more than twenty years ago, I tuned out...
Read MoreYou’re a flipping genius! Opioid prescribing in Medicare Advantage The meat is behind a paywall, but the short version is that it hasn’t changed from 2011 to 2016. Bonus: More than half of MA beneficiaries age less than 65 and disabled get regular opioid prescriptions All this despite the war on providers—things that make you go hmmmm. Socio-economic Status and STAR Ratings The more dual-eligibles you have, the harder it...
Read MoreDesigned to enlighten and amaze Knowing that the diagnosis for sickle cell trait is associated with increased capitation, you decide to screen every patient on your panel. Which of the following is true. A. The diagnosis code can only be submitted for people carrying the trait who were brought back in to be seen and counseled regarding its implication. B. The diagnosis code can only be submitted for those who you treat with aspirin....
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The newly proposed change in Medicare payments has a profound impact on the strategy that I teach young clinicians for generating greater compensation for working the same amount of time. It makes the strategy even more effective. The strategy is based on the premise that most of the compensation in your job comes from actually seeing patients, the rest—the “bonuses,, the “value-based adjustments”—require significantly more work than the additional salary they generate. ...
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