From Tom's Desk

Home meal delivery, free tele-health, enhanced transportation benefits. These are but a few of the plethora of new options in the pipeline for Medicare Advantage patients.

Tread lightly.

These benefits are usually offered because the contracted networks do not have robust primary care services for their beneficiaries. They're an effort to improve both the beneficiary's experience and the insurer's market appeal, but they actually serve both as a center of costs and cost generators---encouraging expensive and usually unnecessary contacts with the healthcare system.

If you're a contracting delivery organization with a well designed care delivery system, see if you can't negotiate away these extra patient benefits in favor of more risk-based revenue.  You'll probably do better financially.

If your system is not that well designed, you should stay away from them as well---you're going to need every extra penny of revenue you can get.

You Should Know...

What a week for United Healthcare.

The Medicare Advantage behemoth, whose experiences in compliance enforcement is usually the best reflection of Federal policy nationwide, significantly decreased it's own compliance liabilities.

The Justice Department announced it was declining to refile an enormous qui tam action that was dismissed on October 6th. Although still under the gun for at least one other significant action, United was able to claim at least partial vindication from accusations that it systematically submitted inappropriate diagnostic risk codes for its beneficiaries.

In addition, United upped the ante on a separate compliance issue when it filed a new motion in its efforts to ask the court to throw out CMS' interpretation of the "over-payment" rule. The rule allows CMS to treat Medicare Advantage over-payments as False Claims Act violations if insurers don’t return them within 60 days of identifying them. The aim was to penalize Medicare fraud and upcoding.

United's suit, joined by more 40 other insurers, seeks to overturn this interpretation, asserting that the rule, by statute, applies only to fee-for-service Medicare payments.  A verdict in their favor will further limit CMS' ability to reduce over-coding and over-payments. 
 

What does this mean to you?

Here come the RACs.

With regulatory efforts and whistleblowing incentives limited, there will be precious few other tools left to CMS in their efforts to rein in Medicare Advantage over-payments. Expect not only significant increases in the activities of recovery audit contractors but also in the yearly CMS “over-coding" RAF adjustment released every April.

That means more documentation requests, greater risk of clawbacks and decreased gross revenue from the same level of risk coding.

Are you and your systems ready?

High-Value Insight

Pathologic vertebral fractures (M80.08. RAF 0.5) are common incidental findings on plain films and the vertebral fracture assessments performed as part of osteoporosis screenings.  If found and addressed appropriately, they can increase your monthly capitation by a full 50%..


However, the code for an individual fracture of the vertebra can only be submitted once---and only at the time the fracture is diagnosed.  After that, you must use a "history of" code for that fracture from then on.

Despite persisting on radiography year-after-year, you risk a clawback if you submit the acute code for a previously diagnosed fracture---and they WILL catch it..

Each new fracture, however, can be submitted with the M80.08 code even if others were diagnosed previously.  Unfortunately, each code is not worth a 50% increase in your capitation---you're only credited with a maximum of one such code per year.

Q&A with Dr. Tom

I'm being offered the chance to participate in a total risk ACO. Should I take it?

Try not to.

"Total risk" ACOs are a different beast from Medicare Advantage.

With Medicare Advantage, you have a pool of money to take care of your patients within a set of guidelines---and you keep what's left over. Pretty simple.

With ACOs, your compensation depends on the difference between what the patient's care “should cost” and what you actually spend. It sounds similar but it's definitely not.

There is much more hand waving involved in the “should cost” calculations. In addition, the disease burden component of those calculations is capped each year, so you could end up being penalized for taking care of a significantly ill patient.  

I tell my young clinicians "if you can't describe your proposed compensation formula while standing on one leg, it's too complex."  The same goes for these different Medicare contracts----except more so because you're on the financial hook for their performance.

If you can't "totally" understand how the dollars flow through a proposed "total" risk contract, don't take it.

It's as simple as that.