The good news? When a Medicare Advantage Patient appeals a decision of denied coverage for a needed test or medication, the decision is overturned more than 80% of the time. The bad news. Patients appeal less than one percent of the time. The lesson? When you’re turned down for care, insist on an appeal. Denying care indiscriminately is what insurance companies do. They just say no to a...
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Actual quotes from physicians, shared to help understand what your peers are saying, NOT to set up a strawman. “Answering calls about yeast infections and runny noses all day—no thank you.” “Sounds dull.” “I want to do something that actually helps people.” I have an answer for all these statements, but for the docs that said them, they are valid concerns. Frequent readers are also bored with reading...
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“Soft codes” are ICD-10 diagnostic codes that are difficult to objectively validate yet generate significant additional capitation. I’ve examined them here, on this blog, in my incredibly popular “Success Codes” series. In that series, I advised you to avoid them unless you can justify their use with extensive documentation. They’re just not worth the risk of claw backs. First, your primes figure out these codes are worth easy money, so they look for...
Read MoreThe Font of All (Medicare Advantage) Wisdom Forbes’ coverage of the open enrollment kick-off There’s more and more coverage of Medicare Advantage in the business press. I wonder why that is? Too many denials has led at least one health system to terminate its relationship with a national MAO Scale this response and the use of denials as a source of cost control may decrease. Is Medicare Advantage three-card...
Read MoreDesigned to Enlighten and Amaze With the disease burden, age and gender being equal, which Medicare Advantage patient is probably associated with the highest monthly capitation rate? A. A patient who became eligible for Medicare due to age. B. A patient who became eligible for Medicare due to disability. C. A patient who is eligible for Medicare and Medicaid. D. All have the same monthly capitation. The shocking answer below: x x x x x...
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Since I started consulting, I’ve been contacted to interview with a number of large health systems that, in the end, declined to purchase my services. Of course, I’ve been contacted by more who have. What was the difference between the non-purchaser and purchaser—besides, of course, that the purchaser ended up doing fantastically well? For months I’ve been trying to puzzle it out. The pitch was the same, the need the same, the potential...
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Every few months I like to re-post my first blog (and most popular) entry to remind us all of why we’re doing what we do. It’s easy to get caught up in RAF scores, care workflows and fraud risk, but it’s the patients we serve that gives it all meaning. They are at the center of everything, something we must never forget. Enjoy Mr. Biondo is a real person and a good...
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Medicare has rolled out an update to its website just in time for the open enrollment period. It’s much more functional and gives you much more information than their previous websites. It’ll be a great tool in selecting your Medicare Advantage plans. The problem is that much of the information isn’t correct. Much is self-reported by the insurance companies—and the government’s ability to confirm its accuracy is a laughingly inadequate. You...
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Boy, such pushback. I’ve recently written about how a recent Federal Court ruling pretty much opens the door to risk-coding however you want. I never said you should lie and make stuff up. True, for now there is no longer any mechanism to enforce accurate risk-coding, and no real penalty for crossing the line. Nor is there likely to be any for some time. And anything that is implemented will be very...
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This is a live report from the SEAK Non-Clinical Careers Conference where I’ve been invited to serve on the faculty. Boy, are health systems in trouble. Attendance for this one little conference is enormous. The numbers of those with the motivation to give up their weekend, travel and spend more than $1000 to explore ways to get out of medicine is higher than it’s ever been. Usually attendees are specialists, this...
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