From Tom's Desk


Whistleblowing is your biggest compliance threat.


For United Healthcare, the hits keep coming.

In yet another recently unsealed Qui tam suit, a pair of whistleblowers accused UHC of keeping “two sets of books” regarding patient complaints—-a key component of star based quality payments.

If proven true, the whistleblowers and their attorneys stand to gain hundreds of millions of dollars as their share of recovery.


Say it with me—-the greatest compliance threat is the potential whistleblower within your organization.


With the growing number of whistleblowers coming forward, it has become increasingly obvious to regulators and Congress that there are organizations that see healthcare fraud as a “business strategy,”---getting caught as simply the “cost of doing business.”


CMS will begin the pushback through funding cuts.  A “cost of business” fudge factor will be figured into capitation calculations. But they'll go beyond simple pushback. 


Make no mistake, perp walks are next.


From clinicians to insurers, it's every leader’s responsibility to create a “culture of compliance” within their organizations.


You fail to do so at your great peril.  

As you can tell from the link above, the big boys have the resources to avoid arrest and prosecution, you may not.

You Should Know...

Reinsurance Opportunity

The average bid on Medicare Part D plans came down for the year 2018—-and average premiums are dropping slightly as well.  This despite the fact that medication spending is increasing faster than other parts of Medicare.

Analysts are falling all over themselves trying to come up with a reason.

Why the disconnect?


Most of the decrease comes from insurers consistently overestimating drug costs in previous bids over the last 5 years.  But at least a little comes from a drop in overall reinsurance rates, a drop that's being seen across the industry.


These unexpected premium changes can be seen as a signal that there may be an opportunity to save some money on your reinsurance.  We stumbled upon this phenomenon years ago, before Medicare part D even existed---and some years we were able to save a bundle.

If you're risk-sharing under Medicare Advantage or some other contract,  you certainly have some sort of reinsurance.  Now is the time to reassess those costs.  Even a small change in rates could ring up big savings---and you never know when your pool is going to need those extra resources.

High-Value Insight

Do Something

This one's a little different, but it’s actually the most important insight I’ve yet revealed.


Do something.


Medicare Advantage can be so complex that it can be paralyzing,


But the beauty of the system is that it’s actually anti-fragile. Change and stress make it stronger.


Trying something won’t weaken it.  At worse, you'll generate information you can use to make it stronger.

At best, you'll generate immense value.


So do something.


Try one thing I’ve suggested over the past five months.


Tailored sputum cultures.   A med reduction visit.   Meet with a local insurer.


Try.  One. Thing.


See what happens.


That’s basically what I did two decades ago---I found a little success and I just couldn’t stop.

Pretty soon the success was overwhelming.


Do something.


And let me know how it turns out.

Q&A with Dr. Tom

Many of my Medicare Advantage patients drop out of the program because they get so many phone calls from their insurer trying to manage their health from afar. How do I address this?


Create your own no call list.


Because most primes are pitiful at managing their Medicare Advantage patients, insurers employ third party services to encourage patients into actions that will increase their revenues.

And with that strong profit incentive, insurers can afford to pay these outside “care management” services in an attempt to pester your patients into compliance.

And pester they do.  Over and over and over again.

In age of intrusive media,  Interruption marketing no longer works.  It's repellent.  You hate it.  Your patients hate it.  They hate it enough to dis-enroll from an insurance they otherwise like.


When the patient gets one of these calls, tell the patient to interrupt the caller and have the caller contact your office.


If the caller does contact the office, have the staff get the service’s contact information. Have the staff tell them you’re taking excellent care of the patient, they don’t need reminder calls and that the patient has said that continued calling will result in the patient's dis-enrollment.


Ask them to put the patient on a no call list.


This works better than you think.


If the caller contacts the patient a second time, ask your patient to provide you with the contact information once again. Have your staff contact your insurer’s provider relations office and request the calls stop.


I pro-actively contact my provider relations office monthly. I provide them a list of my new enrollees and ask them to get them on a “no call” list.


Is it perfect?  No.


Does it help?  Yes.


And if you get the reputation as the clinician who "can stop the phone calls" then your overall reputation will soar.

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