From Tom's Desk


Enforcement Tempo Picking Up

This is a website you should be aware of.  It's the Medicare Fraud Strike Force home page, their listing of the individuals and organizations that have been arrested, charged or convicted with healthcare fraud,  It mainly serves as a deterrence tool, but if you follow it over time,  you'd notice two things of great interest.


First, the tempo of enforcement is greatly increasing. For whatever reason, the number of actions over time is picking up steam---and the greatest increase is seen in Medicare Advantage data compliance actions.


Second, you'd notice what's missing. Big names—household names.  The names that are in the news for massive qui tam actions are completely absent from these criminal prosecutions.


Depending on your level of cynicism, that last finding may not be too surprising. But when both are taken together, it becomes obvious that compliance resources are increasing and they're  be used to target the small and medium organizations and individuals that may not have the means to fight back.


And keep in mind, these aren't civil actions---they're criminal.  Each and every one.


If you haven't nurtured a "culture of compliance" in your organization, it's an investment you're going to have to make. As a greater percentage of CMS' dollars flow into Medicare Advantage, so will a greater percentage of enforcement resources. Your compliance costs will rise in parallel.


Spend your resources wisely. The government is looking for that one whistleblower in your organization. Don't give them anything to work with.

You Should Know...

Peak Medicare Advantage?

It's beginning.


The most recent cost and revenue data for 2016 has been released by CMS and the first selective analyses may be showing a turn in cost and net revenue trends.


A number of trends may be crystalizing at the same time.


We may indeed be at "peak Medicare Advantage.”


To start, recent peer reviewed literature is suggesting that care delivery improvements in Medicare Advantage are spilling over to fee-for-service populations. This in itself isn't surprising, we saw that ourselves in our experience.  Though laudable, the effect may be the tamping down of the fee-for-service costs benchmarks CMS uses to set capitation rates for the Medicare Advantage program each year. 


If that's true, the relatively higher funding of Medicare Advantage (about 106% of FFS Medicare 2017) and the extra benefits patients receive that are supported by that funding may be at risk.  Serious risk.


The next shoe to drop will be yearly capitation rate adjustments that hold steady or even drop slightly when announced next April.

If that happens, look to your care delivery and compensation systems. Make sure they are as efficient as possible.

Because as benefits are cut, enrollment will drop, decreasing revenue and requiring further changes to coverage. 

This feedback loop will put many organizations at risk for significant financial loss---especially the poorly run ones.

Buying in at the peak of anything requires serious hedging.

For Medicare Advantage, creating the most efficient care delivery system is the most effective hedge of all.

High-Value Insight

Fecal Impaction

Fecal impaction (G56.41 RAF 0.3) One of my "secret weapons" for my Medicare Advantage success


It's a so-called "soft diagnosis,” a common problem with no generally recognized definition. So you have to make sure your diagnosis passes the smile test.


In some situations, the diagnosis is absolutely called for:

  • When you have to order a fecal dis-impaction to be performed.
  • Bowel obstruction due to obstipation.
  • Watery diarrhea due to stool blockage.
  • When prescription medication must be used to treat the problem.


Other than that, you have to use your best judgement.


But be careful, you have to assume it's going to be audited.


Document accordingly.

Q&A with Dr. Tom


My go-to hospice just got acquired by a national chain, what do I do?


Be worried.,


The hospice industry is undergoing a consolidation.

Increased regulation and decreasing payments are the forces behind this trend.  And you just might find that a previously excellent hospice greatly changes their ways.


In general, the local and for-profit hospices are the most effective providers.  Unfortunately, those are exactly the ones being acquired.


And once these acquisitions take place, the businessmen take over.  Patient care, though given lip service, generally takes a back seat to cost control.


What you may notice is less responsiveness as staffing, particularly as overtime is cut.

Less coverage of patient benefits may albecome apparent as well,  corporate formularies are generally tighter.

Hospice will only cover services associated with admitting diagnoses. Look for those diagnoses to be as limited as possible so coverage expenses can be limited as well.

And if the medical director changes, that's a huge red flag.


Your tactics?


All the previous quality checks we've discussed in this space stand:


  • Secret shop on a Saturday afternoon and see if they prioritize payment information over patient care.
  • Ask about scope of services.
  • Check staffing rates.


Do these checks every few months or so.


But also be proactive.


Sit down with a few selected other hospices in your area, they may see an opportunity to increase their business through improving their patient care and level of service. Consider giving them a chance.


Losing your favored hospice is like losing a good friend.


Be sad---but prepare to move on.

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