From Tom's Desk

In an effort to avoid repeating myself about the importance of compliance, I have been avoiding commenting on claims of systematic over-coding against United Healthcare.  But the drumbeat is growing loud enough to reassess my take.

Analysis in the medical media include “Everyone does it and CMS adjusts for it,” “It will take so long to adjudicate that it won’t hurt United’s bottom line,” “This is just part of the ‘ongoing conversation” between insurers and CMS about the nature of the Medicare Advantage program.” 

Fines don’t seem to be a deterrent, clawbacks are increasingly seen as the cost of doing business. Even excluding the likes of Cigna from new signups for a period of time is having a limited effect.  And as we speak, the Medicare trust fund marches toward insolvency.  All that seems to be left is prison.

My take?  Any organization or clinicians that engages in systematic over-coding better have the resources of United—or look very good in an orange jumpsuit.

You Should Know...

For several years the CMS’ Center for Medicare and Medicaid Innovation has been internally testing a change in payment design for its Medicare Advantage contractors.  One of the central tenets of the Medicare Advantage program since it’s inception is that all beneficiaries should receive the same benefits regardless of their disease burden.  The payments to insurers may change but every beneficiary has access to all the services that everyone else does.

The new Value-Based Insurance Design (VBID) model aims to change all that.  Under the model, a specific benefit package can be specifically designed for patients with specific chronic illnesses. Patients with CHF could have one set of services covered while someone with COPD could have another.  Leveraging the law of comparative advantage, the VBID model could unleash some serious care delivery innovation, freeing insurers from the cost of having to provide disease specific services to every patient.

Statutory approval of the program lies within the text of The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (Title III, section 301 for you regulatory geeks out there). The law would require CMS to allow, by 2020, any plan in any state to participate in the program and innovate their way to excellent, tailored patient care.

A very exciting example of how attributed, risk based payment models can “unleash the power of Value-Based healthcare.”  Is your system primed to put these opportunities to good use?

High-Value Insight

Once a cancer is no longer actively treated, it should only be identified by a “history of” code.  Appropriately, these “history of” codes are not associated with any increase in the patient’s risk score calculation.

There is, however, an important exception, specifically blood cancers. Leukemia in remission (C95.91) will still increase a patient’s RAF score calculation and be reflected in their capitation payments even if there is no evidence that the cancer is present.  There is no limit to how long after remission this code can be submitted, only that the diagnosis was at some point present, the condition addressed and that intervention appropriately documented during a qualified visit.

Q&A with Dr. Tom

You speak constantly about make care delivery more “efficient”.  What is your most valuable tactic to accomplish this?

I created my own stable of highly skilled specialist collaborators.

They want to make sure they get a steady stream of business, I want my patients to get the best care asap.  Ours interests align and I put that to use for my patients.

I took pains to develop professional relationships with excellent specialists across my spectrum of needs. I socialized with them when I could, came by and personally introduced myself to their office managers and staff. My staff was already exceptional, so it was no work at all to get them to cultivate personal relationships across the offices.

That way, when a patient needed to be seen, they got seen—fast.  Sometimes I pushed the envelope and got pushback from my specialists, but it was always gentle.  Specialists believe the best primary care clinicians are the ones who are smart enough to select them as their go-to resource in need.  Once set in their minds, this story will generate a much more collegial, collaborative professional relationship—to the benefit of your patient’s care.

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