From Tom's Desk

New Narrow Network Compliance Rules Proposed


Responding to analyses by the Office of Management and Budget (OMB) and the General Accounting Office (GAO)—and as predicted in this space—CMS has proposed new regulations that would require active governmental review of both the adequacy of Medicare Advantage Organization (MAO) provider networks and the accuracy of their provider directories.


The proposed regs, which include specific fines and penalties for non-compliance, will require every MAO to upload their network data to a Federal data base where it will be assessed for adequacy and accuracy.


The upload will be required of all new insurers, with existing insurers being required to do so at their three year review.


Over 300 insurers have already been identified for the first round of compliance.


The regs only need OMB approval to go live.


As noted in previous newsletters, MAOs have long used narrow networks as a cost control measure—to some short term benefit but much greater long term cost.  Collaborative relationships have been impaired, innovation truncated, and clinicians disengaged all in the pursuit of the speciality physicians willing to take the lowest payment rates.


Now these insurers are going to have to go on a fishing expedition to broaden their networks, not knowing where to find the most valuable specialty care.


The smart ones will intensively work with their primes and begin to reconstruct the collaborative networks based on true value generation for the patient: Who's timely? Who's responsive? Who's compassionate?


Your primes know who.  And they know where to find them. 

Ask them.

You Should Know...

CMS Spanked Hard by the CBO


In response to the overwhelming evidence of massive, across-the-board overpayments by the government to MAOs, the CBO (Congressional Budget Office) released its report on coding compliance enforcement—and boy is it damning.


It estimates that a whopping 10% or 16 billion dollars of in inappropriate overpayments are being paid out to MAOs every year due to inaccurate code submissions.


That paints an enormous compliance target on every MAO, provider and clinician who cares for medicare Advantage patients.


The report further criticizes CMS for inadequate audit volume, poorly targeted auditing systems and, most importantly, failure to follow statutory requirements to fully expand the RAC program to include Medicare Advantage.


The ramifications for you could be harsh.


These types of analytic reports generally lead to rapid action (see  the inadequate networks discussion above).


With such a damning report, not only is the reaction going to be very rapid, it's almost certain to go over-board.


Validation audits are going to accelerate.


Aggressive RACs are going to come online.


At the very least, your compliance costs are going to escalate.


With narrow margins everywhere, organizations are relying on their fat Medicare Advantage revenue to keep themselves afloat.


What’s going to happen when they have to return up to five years of those previously booked dollars?  

To protect yourself, now is the time to focus on tuning up your compliance.

From personal experience I can attest that once you can prove your compliance credibility with the auditors, they'll go elsewhere for that low hanging fruit--and leave you alone.


Internal audits, givebacks, institutional leadership—there are many ways to get it done.


You have a brief window to get ahead of the compliance curve.


Use it with alacrity.


Use it wisely.

High-Value Insight

Personal Trainers

Develop a go-to group of excellent personal trainers to serve your frail elderly clients; you and your patients will reap rewards.


With physical therapy benefits being increasingly limited and the service becoming more rote, you need to address your patients’ frailty by actually improving their strength and function.


Start looking for personal trainers in your community that specialize in the frail elderly.


Ones who focus on increased functionality and strength. That’s the secret sauce of health—at any age.


Forget about a pile of certifications--you're looking for collaborators with a heart for service.


When you find one, recommend them to a patient.


Be honest that it’s a tryout and see how it goes.


This is not a covered service; the patient will have to pay out of their own pocket.

But as they get stronger and less frail, most will gladly pay.


If it works out, repeat.


You can even use these established trainers to mentor you next generation of fitness specialists.

If appropriate, keep one on the payroll for those patients who can’t pay a trainer privately.


As long as the service is not used as an enurement, it’ll pass regulatory muster.


You’ll find the best trainers for these elderly folks are women—they tend not to over-power the patients. They also probably won’t have been athletic trainers in the past.  And they tend not to have credentials beyond basic personal training.


Personal training is an enormous value-generator for your frail elderly and your own Medicare Advantage performance.


Try it and see.

Q&A with Dr. Tom

Agencies and systems that offer post-acute patient management market heavily to me. They tell me that, for a fee, they can reduce my SNF days and re-admissions.  Should I take advantage of them?  How can I tell a good one?


No and you can’t.


I have yet to see any of these services use total healthcare spending, 18,12, or even 6 months after admission as a marketing metric.


I suspect it’s because they don’t do the analysis.


And even if they did, I'd be surprised if, including their fees, they actually saved you money.

Thirty day readmissions are an easy metric, but they don't mean much.

Total costs over time is what you want to watch.


The best system of post-acute care is for you to see your own patients no matter where they're admitted— acute rehab, in the SNF, in the nursing home.


No one knows them better than you.


No one can take care of them better than you.


They picked you as their personal clinician.


They deserve to have you there when they need you most.


If you’re too busy to do this, then your panel is too large.

Take steps correct that.

Remember, no one does it better than you.




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