From Tom's Desk

A Bad Idea Whose Time Has Gone.


The supportive services extended by care management nurses, aids and social workers can significantly decrease care costs in the short and medium term—though to be fair, long term savings may be another story.  If well executed in a targeted, collaborative manner, the realized costs savings can more than offset the staffing and administration expenses.


Nevertheless, those expenses are real and so is the temptation to offset them directly by somehow billing for the services as they are provided.


Don’t do it.


Billing for these services will require a host of additional overhead as documentation and certification requirements that will spiral up over time.  All this effort will divert your care management crew from doing what they were hired to do in the first place—support your patients.


You’re already struggling to make a profit delivering clinician services through fee-for-service clinical medicine. Don’t duplicate that model by trying to charge for care-management services in the same way. Concentrate on generating value by taking care of the patient instead—which was the whole point of the care management program you created in the first place.


Accept care management as a cost center whose benefit will be reflected in your net financial performance. Rather than trying to bill for services, focus your resources on value-generation through optimal provision of their cost-saving services.

You Should Know...

Why Beneficiaries Choose You

The Kaiser Family Foundation recently released a “Data Spotlight” regarding Medicare Advantage enrollment trends across the country as of March 2017. Some of the trends are no surprise but one, deeply buried, is.

Penetration of the program continues to outpace overall Medicare eligibility with a flat third of Medicare beneficiaries enrolled in a Medicare Advantage plan—a proportion expected to increase to 41% by 2027.

Most of the growth is coming from group plans as organizations recognize the program as the best opportunity to offload the risk associated with their retiree health benefits.


Out-of-pocket costs for both healthcare and pharmacy benefits may be staying stable, but the rising overall cost of care is putting more pressure on insurers and organizations to generate greater revenue through risk-score capture and “quality” bonuses.


Of greatest surprise, though, is the finding that beneficiary enrollment in plans with high star ratings have been flat for the past several years.  Pushed primarily as a means for patients to identify the “best” plans, it was expected that the plans with the highest star ratings would see the greatest growth in covered lives, especially since five star plans can enroll anyone at any time.  


Rather, marketing research now confirms that beneficiaries don’t use star ratings to decide on which plans to sign up for. They focus, instead, on benefit structure, out-of-pocket costs and provider networks.  This suggests that the way forward for insurers and organizations to grow their products and revenues is to concentrate on these factors to promote beneficiary recruitment, especially given the ephemeral nature of “quality” programs and the tendency of those programs to be “adjusted” into irrelevance over time.



If you want to grow your product, make sure your benefit design is competitive and your provider network is strong—that’s what your potential customers are looking for.  Covered lives, not transient “quality” programs, are the true coin of the realm.

High-Value Insight

Missing Ventricular Fibrillation

Patients with implantable defibrillators for history of ventricular fibrillation are appropriately diagnosed with a “history of” code.  Except when the device goes off.

It is not unusual for me to see patients whose defibrillator has fired and if, upon interrogation, the device reveals a discharge for ventricular fibrillation then the v. fib code of I49.01 can be submitted with the appropriate documentation.  As you would expect, the “history of” carries no risk adjustment but the v. fib. code does—significantly so.

Don’t miss the opportunity to capture this risk code when it presents itself.  And it will.


Key Idea

If you see a patient with v. fib because their defibrillator discharged, document appropriately and code the v. fib.

Q&A with Dr. Tom

What are the best opportunities for an organization to control costs by internalizing them?


Durable medical equipment (DME).


DME runs the gamut from canes to special air beds.  Most insurers try to control these costs by negotiating down fees with DME suppliers in exchange for volume.

Even so, DME represents a considerable expense for most providers—and to the patients who have to pay for an out-of-pocket portion as well.


Innovative organizations can offer patients the option of free new or previously owned lift chairs, walkers, canes, wheelchairs, and motorized scooters for their mobility and safety needs.  When done in bulk, these services can save serious dollars for all parties and providing them gratis avoids any number of Medicare regulations—as long as they are offered as a charity at need and not as an improper inducement for enrollment.


Certainly at some point along the spectrum of need, expense and complexity, there lies a point where the lines cross and it’s just not worth it doing it yourself. But for the high volume items, you can get your patients' needs met and save everyone money at the same time.



Consider internalizing the provision of at least some DME though a charity arm. It can save costs for you, your insurer and your patient.

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