From Tom's Desk


Think of risk codes as one more form of digital currency---kinda like Bitcoin.


In fact, you can call them “Riskcoin.”


Bitcoin and “Riskcoin” have a lot in common:


Both exist only in the virtual world. 


To "mine" on a large scale, both require the use of computers.


Mining for either has created a specialized class of data wizards dedicated to their efficient creation (I should know, I'm one of them).


As their perceived value increases, an enormous amount of resources are being dedicated to their recovery.


The numbers of both are limited:


  • The number of Bitcoin is limited by design to 23 million.  And the value of bitcoin infinite--- limited only by what someone is willing to pay.
  • The number of Riskcoin is also limited---in it's case by the number of risk diagnosis in the population of patients covered by Medicare Advantage.


However, there are some important differences---and herein lies the lesson.


CMS adjusts the value of risk codes every year, compensating for the efforts of "mass mining."  In addition, the amount of money associated with each risk code draws from a fixed pool of dollars as determined by CMS.

The result?

The more RiskCoins are created, the less each one is worth.


So the mad rush to "mine" so many Riskcoin is making each one less valuable.


But the differences are even more profound:


  • Once a Bitcoin is "mined", it stays in existence---nothing more needs to be done.
  • Once a Riskcoin is “mined," it disappears after a year and resources have to be consumed to conjure it into existence again---requiring an extensive permanent infrastructure to maintain it's value.


And worst of all:

  • Once you have a Bitcoin, you don't have to spend it on anything unless you wish.
  • Once you have a Riskcoin, your going to have to spend a certain number every year purchasing healthcare---a further "tax" on their value.


The "mass mining" strategy in the Medicare Advantage space is getting pretty crowded

Set up a Medicare Advantage plan, generate as many Riskcoin as you can, encourage enrollment by sharing some of the revenue with beneficiaries in the form of extra benefits.

And leave cost control to the failed strategies of the past.

Your strategy is clear.

Be a contrarian


Find the sweet spot of getting the most Riskcoin for the least cost. And then invest most of your effort in making sure they're spent efficiently.

Don't pay for a "mining" infrastructure---build an "efficient spending" one.

When the Riskcoin bubble pops, your's will be one of the last plans standing


That's how you win at the Riskcoin game

You Should Know...

Aetna + CVS



The proposed Aetna/CVS merger is all over the news. 

There are a large number of synergies that can be generated by the deal, but for a major one---efficient healthcare delivery through in-store "Minute Clinics", there is less than meets the eye.


Much ink is being spilled as to how these modified urgent care clinics are going to bend the cost curve on Aetna's Medicare Advantage products and make them more profitable.


Don't count on it.


Healthcare is a service that stimulates its own demand.  The more contacts the patient has with the system, the more patient contacts will be generated.


That effect is amplified as the training level of healthcare contacts decreases. Going to see a physician in their office will generate less additional demand than seeing a PA in a drug-store clinic.


I'm certain there is much value to be had if the Aetna/CVS merger goes through, but bending the cost curve for their insurance products because of 10,000 "Minute Clinics" isn't one of them .

Don't include it in your value calculations.

High-Value Insight

Metastatic Cancers


Cancer, even metastatic cancer, is quickly becoming a chronic illness. It’s increasingly managed by primes rather than oncologists. And it's very easy to miss the metastatic cancer codes when seeing these patients.


Cancer patients with metastases are coded with two codes, the primary cancer codes and the metastatic code. 

The point of this segment is not to give you these codes, there are far too many, but to be aware that if you're the one managing these cancer, you simply cannot miss them---they're associated with far too much revenue not to be addressed.

There are many of these metastatic cancer codes, they're organized based on the site of the metastasis and NOT on the identity of the primary. They live in the C7xx family of the ICD-10 system.  

And they will more than double your monthly capitation.

If you, rather than an oncologist, are taking care of a long standing, smoldering cancer (and if you're risk sharing you really should) then make sure you don't miss the metastatic cancer codes, as appropriate.


If that cancer ever wakes up, both you and your patients are going to need those resources.

Q&A with Dr. Tom


Should I backdate referrals for specialists?




And only if the specialist is worth it.


"Backdating" describes a vendor, usually a specialist, asking you to sign a referral for services already performed.  Backdating is usually required because of administrative inefficiency in the specialist's back office.

More than a few specialists, however, use backdating as a strategy to get around your role in attributed insurance programs such as Medicare Advantage.

In these programs, beneficiaries agree to select (or "be attributed to") a personal clinician through who they agree will coordinate all their care.

A primary method of doing so lies in the prime's authority to direct specialty care in directions that they, in collaboration with their patients, deem appropriate. It's an important authority, as at least some of your compensation is dependent on controlling your patient's healthcare spend.

Some patients, though, agree to the terms of their health insurance with their fingers crossed behind their backs.  They seek out the extra benefits associated with attributed plans with no intention of allowing their prime to direct their care.

They still go directly to specialists. They fib about their coverage and get their care.

When it comes to this kind of deceptions, more than a few specialty clinicians find themselves easy to deceive.  It's the responsibility of any office to confirm coverage before providing any care.

When the specialist finds the deception, they will find they can't get the insurance company to pay them without a referral from the prime dated on or before the date the service was provided.  

So they ask you to create one.

Should you?

Theoretically, you should never backdate referrals---it can be interpreted as fraud.


But if the service is actually performed and there is no evidence of bad faith, I would consider it.



Have your office manager speak to their office manager.  Educate them. If they seem teachable, consider their backdating request.




Only do it this one time and make that fact clear.


And if they call again, tell them no.


It's the burn that best teaches to fear the fire.


If you tell them no, they may not see your patients ever again, they may turn your patients against you, they may even complain to everyone from your employer all the way to your state medical board.

None of which have any standing.  They might as well accuse you of not helping them defraud an insurer.

The real teachable moment here is for you.

Requests for backdating referrals will teach you what patients and specialists to avoid.

And with life being so short, that's possibly the greatest professional lesson of all.

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