From Tom's Desk

Reflections on Payment Shifting


More reflections on what we’ve learned from these weekly doses of value over the past six months.

Resource Shifting


CMS is adjusting risk score calculations to  shift resources to underserved populations.  You’re probably making enormous investments in risk-code identification and acquisition.  Unless your plan’s beneficiaries are made up of these underserved populations, you may find the payoff of those investments less than you expected.


We're still in the earliest phase of this form of payment targeting.  It's very much analogous to the time when risk coding was just taking off 15 years ago.


Organizations that can get ahead of this curve and create effective care systems attractive to these underserved populations may have as large a payoff as we did when we anticipated how risk-coding itself was going to change the game 15 years ago.  At the very least, expansion into targeted populations can mitigate the revenue loss that’s going to occur as payments for less disadvantaged beneficiaries are decreased.


This is the largest, and perhaps last, such opportunity organizations will have to front run the Medicare Advantage program.  Those that take advantage of it will generate sustainable returns that will be the envy of the rest of the industry—-and perhaps generate some societal goodwill as well.

You Should Know...

Malnutrition Perils...


Malnutrition is a key condition to address in patients with co-morbid chronic diseases. Addressing it enables your patients to stay strong and help deal with their disease burden. It also allows you to generate additional revenue to offset the costs  associated with chronic disease patients who are sicker than average—-as reflected by the presence of the malnutrition.


Since 2014, CMS has been reviewing the inappropriate submission of certain malnutrition codes for both DRG and risk-based payments.


Kwashiorkor and Nutritional Marasmus are both rather esoteric types of malnutrition with specific definitions.  They’re rarely found beyond the developing world, yet they had been submitted for payment with surprising frequency.


Now there's new evidence that CMS’s reviews are having an impact—-in both good and bad ways.


The good?  Inappropriate submissions of certain malnutrition codes are decreasing, saving the Medicare program millions in inappropriate payments.


The bad? Reviews seem to be extending past these unusual conditions and onto more “mainstream” malnutrition diagnoses.


Your challenge?  Make sure you only submit malnutrition codes that are supportable and appropriately documented---and stay away from the red flags.


Your tactic?


See the high-value insight below.

High-Value Insight


...And Promise

Never, ever let a diagnosis of Kwashiorkor or Nutritional Marasmus out the door without a diagnosis specific review.  


It’s so rare a diagnosis as to be almost always used incorrectly.  With the exception of immigrants from the developing world, seeing either condition in your community should set off all sorts of public health red flags—-social service, child protective services, elder neglect hotline.  If one of those codes are submitted and there’s no documentation of those resources being mobilized, your organization has provided very poor care.


Make sure you have a set of objective internal diagnostic criteria that must be documented before either diagnosis is submitted. If your clinician's documentation is insufficient, send it back to them for review. If you send it back though, be sure you don’t send along information that could be construed as leading or guiding your clinician to a different specific code. Eventually your clinicians will get the picture and stop submitting the problematic codes in favor of ones that are more accurate that your organization won't reject.


You absolutely must assume these diagnoses are going to be audited.  Kwashiorkor and Marasmus are examples of two rare diagnoses associated with increased payments that are easy for auditors to target. Addressing the challenge pro-actively will send a message to auditors that they should move on to more fruitful fields---that is, providers who don't do such a good job of pre-submission code vetting.  You'll be able to book your revenue with confidence that it will be retained and never clawed back.


A special caveat.


While uncommon in the developing world, these codes ARE common in refugee populations, especially upon their initial presentation for care---I've seen it. If a patient has one of these conditions, by all means submit it—-but do yourself a favor and make sure your documentation is up to snuff, because an audit is guaranteed.

Q&A with Dr. Tom

As I catch more chronic diseases in my Medicare Advantage patients, they’re constantly contacting me with questions about the medical information they see on their internet portals.  How can I save myself some time?


Be proactive.


At their yearly visit, ask them if they look at their “patient portal”—-most don’t.


If they do, bring a laptop in with you into the exam room. Ask them to pull up their account and, in front of you, go through how they interact with their interface.


Address any questions they have, but specifically go through their problem list and risk diagnoses.


Finish the experience by asking if they have any questions.  When they say “no,”  they'll enter into a subconscious contract with you that indeed they don't have questions.  Because they've made this "agreement"  they'll be even less likely to seek you out with specific queries about their patient portal.  This persuasion technique, called  internal consistency is an incredibly powerful tool.  We'll review other uses in future publications.

If you don't think you have time for this,  consider that the problem is not the complexity of the suggestion, but other factors; such as the construction of you practice, your compensation formula and your priorities.  Review those foundations before dismissing a patient portal review out of hand.

There's really no tactic that'll generate true value if you are taking care of too many patients.

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