From Tom's Desk

VA Improvements Put You at Risk

The Veteran’s Administration is making great strides in improving the care of its beneficiaries.

Although still far from perfect, wait times are decreasing, clinical and administrative deadwood is being pruned and and outcomes are improving.

More vets are giving it a try.

Great news.  

But a challenge to your Medicare Advantage panel.

Many veterans who get their care through the VA hedge their healthcare bets by also enrolling in a Medicare Advantage plan. Medical care delivered by the VA is not paid for out of your Medicare Advantage pool. However, the medical documentation from the VA is not used by CMS to calculate your monthly capitation. 

Fail to see them at least once a year and your capitation amount will be calculated as if they have no chronic illnesses at all.

But if they receive care outside of the VA system, you're on the hook for the costs.

In effect, if you don’t see your patient at least once every calendar year, you could have a very ill patient with a very low monthly capitation show up very sick in a non-VA ER and generate huge costs for your pool—with no offsetting capitation for years.

On top of that, CMS down-adjusts the base capitation rate based on the percentage of enrolled VA eligibles in your area.

As more and more veterans opt for the free care of the VA, your collaborative relationship will suffer and they’ll be less likely to see you every calendar year for your health maintenance/code collection visit. Your risk for a catastrophic loss will increase.

If you check, I’ll bet you'll find far more of the patients on your Medicare Advantage panel get their care though the VA than you realize.

And as the VA thankfully improves and more vets age into Medicare, your challenge in caring for them is only going to get worse.

You must make a conscious effort to get them in every year. A personal effort.

They’ll be more resistant than the average patient. You’ll have to make a strong value proposition to get them in, especially as the VA does a better job.

But you gotta do it.

You’re taking on more risk than you know.

You Should Know...

Orthotists May Be Able to Submit Risk Codes

In Washington, HR 3178 just got voted out of the House Ways and Means Committee this week and will soon be voted on by the House as a stand-alone measure. 


Once law, the bill will, by statute, allow the medical record of orthotists to be accepted for evidence of medical necessity in the payment for prostheses.


Those records would also become “qualified encounters” for collection of risk codes, including some that are easily and frequently missed—such as amputation codes and diabetic neuropathy codes.


The bill is strongly bipartisan and expected to be passed by the end of the year.


I’ll let you know when it takes effect. These new rules may go far toward improving your capitation—and all it’ll take is strengthening the relationship with your collaborators.

High-Value Insight

Acute Kidney Failure vs Acute Kidney Injury
What You Need to Know


Acute kidney failure (AKF) (ICD-10 N17.x) is a common and easy-to-catch diagnosis that’s also under-diagnosed and easy to miss in an outpatient setting, especially in nursing home patients and the frail elderly.


With many potential complications, including dialysis, it’s associated with a significant amount of increased monthly capitation for your Medicare Advantage pool.


In contrast to the outpatient under-diagnosis discussed above, in the inpatient setting, the condition is actually very frequently over-diagnosed. Despite its clear-cut definition, it’s often confused with Acute Kidney Injury, a less serious condition that's associated with no additional capitation.


This combination of over-diagnosis and a black-and-white definition means it’s also a common target for audits.


Learn the definition, apply it correctly, and you’ll be able to treat the patient appropriately, capture the additional revenue and, in an audit, be absolutely bulletproof.

Q&A with Dr. Tom


My patient’s ask me for all sorts of advice about their Medicare Advantage coverage.  I really have no idea how to answer accurately.  How can I address their concerns?




Refer all their insurance questions back to their insurance agent.


Do everything you can to engender a close, collaborative relationship between your patient and their agent.


Create the expectation that their agent is their own personal insurance assistant.


So if a scammer gets past the door and tries to sell them on a new policy or service, they know to say, “All requests have to go through my agent.”


Did they not use an agent?


Tell them to get one.


Patients have no idea the value attached to their Medicare  Advantage benefit. They are faced with relentless scammers and thieves.


I simply tell patients to ignore any information about plans or benefits that don’t come from their agent.


How can I do that?


I know all the local agents very well. I collaborate with them. I know they take good, ethical care of their clients.


I’ve made it a personal policy to know them all.


In the past, when one of my patients got scammed into changing their coverage—and it happened ALL the time—it was me and my staff that had to pick up the pieces.


Not any more.


Not now that each one has their own personal agent.

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