If you’re a single speciality primary care group or even a multi-speciality group without your own imaging center, consider buying your imaging studies in bulk from an outside vendor and then using them on the patients in your panel as the need arises.       Check your Medicare Advantage contract, but many will allow you to service your patient outside your contract without charge.       If yours does not, ask your...

  If you contract with an outside service to help you recover diagnostic risk-codes and those codes are rendered invalid through a whistleblower suit, it’s your revenue that’s going to be clawed back.       I’m not just taking about the standard CMS audits (although if extrapolation becomes official policy, those audits will become more dangerous too). I’m talking about qui tam and whistleblower lawsuits.       Code-harvesting arrangements usually involve the health system...

  I’ve seen this in two different organizations who don’t financially risk-share with their physicians.     Their clinicians do no risk-coding.       None.       Zero.       Their back office coders extract risk-codes from the documentation of every office encounter and submit them in aggregate to their insurance partner through a spread sheet.       They know that even if their own internal staff misses a code, their...

  An executive recently contacted me asking how to transition their medical staff to a financial-risk compensation model which included a downside for the clinician.     Here’s what I told her:   Create a model you are comfortable with and that meets your goals—define the population, the split, the frequency of reconciliation, etc… Invest in the infrastructure required for regular financial reporting in an understandable manner as we’ve discussed so frequently in this space....

    As new insurers enter the Medicare Advantage market, that’s you’re opportunity for taking advantage the many opportunities we discuss in these pages.       Shop around for your own reinsurance coverage (don’t take theirs at an initial low rate, they’ll just jack it up later when they’ve become established). Ensure that you have vendor options for carve-ins like home health and hospice. Enshrine escalators into your monthly stipend payments so as you...

  Your Medicare Advantage insurance partners are doing everything they can in their contracts to push care costs down to you.     You can be certain they’re altering your contracts, debiting you for expenses you’re not responsible for and hoping you won’t notice, they’re even taking kickbacks and giving exclusive rights to certain vendors to service your patients—and charging the higher-than-market rates to you.     This is all cynical, I know. but it’s...

  If your organization takes downside financial risk from your Medicare Advantage insurer (and if you don’t you soon will), then you have some sort of line item for “stop-loss insurance” to protect you against an adverse experience.       Stop-loss insurance covers you in case a patient’s care costs exceed a certain threshold—it keeps you in the game when you suddenly have an unusually large number of patients pop up with health problems....

    Your biggest risk from whistleblowers is the primes in your organization.   They’re collecting information that they will use to file a qui tam action in case they get terminated or as a nest egg when they decide to quit.   These suits are usually settled without admission of wrongdoing but they can be pricey.   Your primes are being targeted by False Claim Act attorneys over social media for qui tam actions.  ...

    The capitation for “Dual-Eligible” or Medicare-Medicaid patients under Medicare Advantage can be as much as 30% higher than that of “regular” patients.     So why aren’t you doing better with them?     They’re not “sticky.”     They don’t stay with their PCP, often changing after only a couple of months.     They’ll also more vulnerable to illegal inducements to switch, often accepting payments to change primes or even insurers....