From Tom's Desk

Qui Tam Dismissals

After a Federal Judge dismissed the multi-billion dollar qui tam suit against United Healthcare on October 5, the Justice Department announced this week it was dropping the matter entirely and will not refile the complaint.  One cannot help but feel for the whistleblowers who briefly thought they were looking at a $100m payday.


Ostensibly good news for United, but perhaps not for the rest of the industry.


The suit was dismissed due to a lack of specificity of the allegations, a result of the shear size of the suit.


Given the scope of alleged overpayments, system-wide compliance experts now believe the thrust of further enforcement efforts will be a combination of smaller, more specific qui tam actions and a much heavier reliance on recovery audit contractors.


With billion dollar recoveries from large insurers through these qui tam actions off the table, smaller organizations with fewer resources must look to their internal culture of compliance---or be prepared to pay.

You Should Know...

Star Rating Trends

This week’s of Medicare Advantage Organization star rating data by CMS revealed several telling trends.


There was a decline in the 384 active Medicare Advantage plans rated "high" (with 4 or 5 "stars") compared to one year ago---44% vs 49%.


However, despite the drop, the percent of Medicare Advantage beneficiaries enrolled in these high performers actually increased---73% vs 69% one year ago.


Finally, the number of the highest performers, those with a five star rating, remained the same at 23. Moreover, the identity of those highest performers have tended to stay the same from year to year---and they tend to be the plans with the longest experience in the Medicare Advantage program.


The take home?


The market is steadily consolidating toward the plans with the most experience in the Medicare Advantage program.


And the star system is giving them an incumbent advantage that is increasingly difficult to overcome.


Later market entrants are going to have make sizable capital investments to catch up. Especially since achieving the higher ratings are becoming increasingly difficult (by design) as years pass.


Or, these newer organization can decide their capital outlays are better spent creating better care delivery systems and forgo the financial bonuses and other benefits of a high star rating.


Sometime the only way to win a game is not to play.

High-Value Insight

Inflammatory Spondylopathy

Patients with Inflammatory Bowel Disease (IBD) often have co-morbid arthropathy that's routinely missed.

Always review the plain films of IBD patients for spondylosis or other inflammatory changes of the joints.

These are commonly found in the thoracic and lumbar spine but can be seen anywhere.

If present, in need of treatment and appropriately addressed, the diagnosis of specified inflammatory spondylopathy (M46.5x, RAF .40) can add 40% to the monthly capitation your insurer is paid to cover the care of the patient.

Look for it. you'll be glad you did.

Q&A with Dr. Tom

P.B., an NP supervisor from a large academic medical center writes:

"I work mainly with hospital based and specialty based NP’s/ PA’s.  Due to ‘subsequent to’ billing, we are often looking for ways to show our worth / productivity since we can’t rely on billing alone like physicians."



Phillip, to demonstrate your value, you're going to have to DO SOMETHING.


To generate a different result, you must take a different action.


Working within the status quo will have you standing in place year after year after year.


YOU must take the initiative for change, either institutionally or individually.


No one else----YOU!


I recommended to P.B. a straightforward demonstration project that I would normally charge five figures to implement but that he could do on his own for free. I don't know if he'll take me up on it.


But he has to do something.


Otherwise he and his staff will remain being seen as centers of cost generation rather than centers that generate value.

My full reply is below.  The short version:

Teach a small number of your highly motivated clinicians to risk-code, have them independently record their efforts over a short period of time and present the results to the administration.

Show them the dollars you can generate.  And if they're not interested, find someone you can work for who is.






Phillip B.


That's a tough challenge. Like most NP?PA’s in this position, "subsequent to" billing has reduced your highly skilled colleagues to the equivalent of line workers in a factory.


Administrators looking at net financial performance will only see them as cost centers and act accordingly---working to replace their services at the lowest possible cost.


You, of course, already recognize this and with no information on your organization's contracts or compensation structure it is difficult to advise you.  


However, if your organization has significant managed care exposure, either Medicare Advantage or managed care Medicaid, then one simple way is to use those "subsequent to" encounters as an opportunity to collect “risk” codes. You've probably been trained on this out the wazoo, but the training has probably been done ineffectively and with so many other responsibilities such clinician “code collection” is probably not being done well.


A mini risk code collection pilot project can be an effective tool for NP/PAs to demonstrate to administrators their hitherto unrecognized value in a real, dollar based manner. It’s a pretty easy, straightforward initiative with data which you can collect in a short period of time. And though the actual dollars won't show up in the system for 12-18 months, simply showing the risk code collection stats can be a great starting point for discussions of value and compensation.


So this is what you do. 


Pick a group of 4-6 highly motivated NPs/PA's---the really sharp ones. Get them on board through a frank discussion of the reasons behind the initiative---specifically to demonstrate their value in an attempt to improve their compensation. Educate them on a small, focused group of risk codes specific to their clinical situation that are easily missed (how to identify them, document them, etc . . .) and have them start looking for them during their daily encounters. You can use my “Success Codes” blog series  as a resource (no advertising, no email address collection, no selling, just education). 


Now, your organization probably has coders looking for these risk codes in the background and may even have coding prompts in the EHR, but experience teaches that these are missing a lot of opportunities that only a specifically educated clinician can identify.  Over the course of 30 days, have this focus group keep a paper and pencil list of every risk code they collect and document---no need to record names or other PHI, just a list.  If you want to get ambitious you can sort them by patient #1, patient #2 etc. At the end of 30 days, present the list to the appropriate administrator as an example of how effectively a highly motivated group of your fellow collaborators can impact the bottom line. More risk codes=more revenue. The administrator can compare your risk code lists against a randomly generated matched list of patients if they need harder data.


Of course, doing this runs the risk of simply having additional responsibilities (i.e. risk code collection) placed upon your colleagues with no additional compensation. Your response should be “You can place these new work requirements on us if you wish BUT if you want this done effectively---so it actually generates revenue that is not vulnerable to claw-backs—-you’re simply going have to pay for it.”  


You’ll probably get a lot of harrumphing about inurement and kickbacks but there are perfectly ethical and legal compensation systems that incentivize appropriate risk code collection---such arguments against compensation are the equivalent of “we just don’t want to pay for it.”


Those arguments are also a sign to look for a new job with an organization that does “get it.”


Please understand that I find it distasteful in the extreme to rely on data other than direct patient care to demonstrate a clinician’s value. Medicine is not supposed to be a game, it’s supposed to be about healing and compassion. But until our work to change the system from within comes to fruition, data is the language we all must speak.


As you can tell from the length of this message after working alongside NPs and PAs for two decades, seeing these highly trained clinicians relegated to the role of line workers is deeply upsetting, so I decided to spend some of my time on the train to throw out a suggestion.


Good luck and let me know if I can answer any questions.


And thanks again for the follow, the likes and the retweets---the more clinicians I can reach, the more content I am.





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