Check Your Contracts for Carve-In Rates

      “Carve-ins” are benefits offered to your patients the cost of which are included in your capitation.     If you’re financially risk-sharing, that means part of the costs of those carve-ins are are coming out of your pocket.     Yet you have no control over how much you pay for those benefits, your Medicare Advantage insurance partner does. And they have many other objectives other than maximizing the value of the...

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Having Your Clinicians Start Taking Downside Risk? You Must Do This First!

When organizations tell their clinicians they’re going to have to take downside financial risk through medicare advantage, they do just that, they emphasize the downside.   They don’t do a good job telling their staff about the possible upside and even more importantly, how to best achieve a benefit.   In fact, when I’m contacted by a health system in trouble with their medicare advantage contract, I always find that that they were flippant when...

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How Transparent Are You?

    If your organization is being forced into insurance contracts with downside financial risk, you’re going to be tempted to pass at least some of that down to your clinicians.     And if you do that transparency is essential.     You must be candid with your clinicians about the rules of these contracts.     You must be clear as to what behaviors from them are desirable as you try to make...

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The Big Twelve

    Recently a faithful reader asked me to review the “Big 12,” that is the twelve diagnostic codes I always keep in mind whenever I see a Medicare Advantage patient.   Here they are with the documentation requirements to keep you out of trouble (and a couple of acute codes thrown in):         Atherosclerosis of the Aorta I70—need radiographic evidence.     Chronic Bronchitis J41.0—h/o smoking or other chronic irritants (dust...

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Telemedicine Precautions

  An informal survey recently showed that of more than 20 telemedicine services, not one was compliant with the rules established by the medical boards in every state they practiced in.   Not one.   Don’t take a consultant’s word for it. Internally check with your states’ board of health.   The real risk here is that there’s a malpractice action. If you’re not complying with the rules, that really impairs your defense—and cost you...

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Downside Risk Coming to Organizations—But This Time, It’s Actually Happening!

    The recent AMGA” Payer’s Survey” revealed that 20% of health systems expect to be forced to take downside financial risk in the next two year, up from 3% in the last survey.   Downside risk is nothing to mess with. If you execute it poorly, the costs will be dear—maybe even your job.   You must get ahead of this. If you haven’t had a discussion with your payer about their future plans,...

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In Six Months, Telemedicine is Coming for You

  Imagine your organization as a castle. Outside are all your patients demanding healthcare and within is the healthcare they want. Healthcare that, under your Medicare Advantage contract, you’ll be paying for.   And your medical staff is on the walls judiciously allowing your patients to get the healthcare they need.   Chances are, in six months your Medicare Advantage contracts are going to include a telemedicine component.   Telemedicine will be very much like...

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A Robust Nursing Home Presence is Essential for Your Organization’s Medicare Advantage Success

    A robust nursing home presence is essential to your Medicare Advantage success.   Even if you internalize that cost-center and have your own facilities, encourage the clinicians on your staff to consider serving as a medical director for a local nursing home or rehab facility.   Match their medical director fee. Compensate them for the clinical time they have to give up to serve in that capacity.   You will more than make...

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