The Greatest Threat to Your Medicare Advantage Revenue: Not Compliance Enforcement But Rather Competitive Bidding

Up to the last month, I’ve been predicting that it will be a “compliance backlash” against all the fraudulent risk-coding and other data submissions that will greatly reduce the revenue of Medicare Advantage organizations (MAOs)—reducing the profitability of high-margin plans and sinking all others.     Experience teaches that I’m right about the system pushing back against the excessive revenue harvesting, I may, however, have been mistaken about the catalyst.     There has been...

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Sunday Links

Such penetrating insight! How do you do it?   How telehealth will drive value in Medicare Advantage Basically a press release by the telemedicine industry, but still of interest.     Another whistleblower case regarding over-coding of Medicare Advantage patients Lessons learned from this case:   If you’re caught intentionally over-coding, fix the system and don’t do it again. If you’re not among the largest Medicare Advantage providers, don’t cheat. Treat your coding staff with...

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Saturday Quiz

Designed to amuse and enlighten.     A patient you haven’t seen in over a year underwent a bone density test where an osteoporotic compression fracture was noted. Do you:     A. Submit the code for the pathologic vertebral fracture using an addendum to the test interpretation charge. B. Invite the patient to come in and discuss. C. Call the patient to inform her of the diagnosis and submit the code from that call....

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Picking the Right Service to Work With

As a clinician, the telemedicine service provider you work with should pay you more if you have to sign up for shifts and/or do more than minimal charting.     The standard fee paid to a clinician for a primary care telemedicine encounter is currently $23. If you have to fill out past medical histories or enter allergies, you should ask to be paid more.     Your employer uses your free labor to subsidize...

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Your Doctor Might Not Be Covered By Your Medicare Advantage Plan

Remember the reference book the insurance salesman gave you when you signed up for your Medicare Advantage plan. The one that included a list of all the doctors covered by your you plan.     The government says it’s wrong more than half the time.     I suggest you sit down with the list of doctors you’ll want to see and call the office manager of each of them. Ask them if they really...

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A Christmas Wish for You

Your company’s disability insurance is useless.   Read it close. To pay off you’ll have to be totally disabled and required to prove it year after year—even after you get social security disability.   As a skilled professional, you’re far more likely to be disabled from your own occupation while not being disabled enough to, say, keep you from working at Wal-Mart.  If that’s the case, your company’s disability insurance won’t pay off.   Get your...

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A Holiday Gift

In honor of the holidays, I’m going to share with you the secret to excellent net Medicare Advantage performance.   One of my clients just found out that her use of this knowledge generated more than $600k in net revenue for her this year—and I’m offering it here to you for free.   Spread it around. Use it to succeed. Look like a genius. You don’t even have to attribute it to me.   Grow...

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Sunday Links

Darn it, where does she get all her information?     This article in the Washington Post takes a political angle on Medicare Advantage. What’s interesting is the government touting a six percent YOY decrease in Medicare Advantage premia vs. only a 3.6 percent drop in traditional Medicare—not costs, just premia. Of course, Medicare Advantage premia are dropping because the one thing insurers need to gain access to the revenue stream associated with a patient’s...

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Saturday Quiz

Designed to enlighten and amaze   As you personally contact the patients on your panel who haven’t seen you yet for their yearly visit, you come across one who, though relatively healthy,  is particularly resistant to your entreaties. You should:   A. Threaten to kick them off your panel. B. Offer to do a home visit at no charge. C. Offer to pay them to come in. D. Tell them their co-pays are going to go...

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Is Your Employer Actually “Risk-Sharing” With You?

If your organization claims they’re risk-sharing but you’re not seeing any real financial benefit, they may just be pretending to risk-share to gain your compliance while having no actual intention sharing the financial benefits of your mutual success.   This is a sadly common situation.     Red flags to look for:   Your employer devotes great resources in encouraging you to perform the specific tasks which advance the value of their Medicare Advantage contracts—such as...

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