From Tom's Desk


Work Requirements Won't Save the Day

Managed care Medicaid has had a rough year, but some relief may be on the way.


CMS has approved plans to allow states to include some sort of work requirement as a condition for participating in the Medicaid program.


Given the problems private companies are having delivering Medicaid benefits sustainably, this waiver should surprise no one.


The idea is to decrease the role numbers and decrease expenditures.


The problem?


The waivers within the waivers.


The elderly, the infirm, and the disabled are spared the work requirements. They are going to be ones left on the program---and they are the ones who cost the program the most money.


Private Medicaid contractors will look toward work requirements to ease the cost pressures on their margins.


They will push for them in your state.

But they will drive away the least costly patients, the ones most amenable to care management, the ones who could, if managed correctly, provide a real buffer to offset actual care costs.


So, at least for private Medicaid contractors,  don't count on them working.


Count on them making things worse.

You Should Know...


Medicare Advantage Enrollment MUCH Higher Then Expected...

But as a subscriber, you knew this already.  

As predicted in this space three months ago, Medicare Advantage enrollment far exceeded even the most generous estimates.


Total enrollment for 2018 is estimated to be at 21m members, an increase of 8% — much higher than the 5% increase that represented the highest estimates at the beginning of sign-ups.


And as you might expect, the sign-ups for the highest STAR-rated plans increased at a far faster rate than the plan with an average STAR rating. Whatever the financial advantages to high STAR ratings might be, the marketing benefit clearly seems to be the largest.


With total revenues paid out of the program topping $200b in 2018, the Medicare Advantage bull looks like it has much farther to run.

High-Value Insight


Chronic Kidney Disease Stage III

Beginning in 2019 you will get a capitation adjustment for your patients with chronic kidney disease (CKD) stage 3 ICD-10 N 18.3.



CKD3 is defined as an estimated glomerular filtration rate (eGFR) between 30 and 59 measured twice at least two months apart.



Without these measurements, an auditor will default your diagnosis back to Chronic Kidney Disease, Undefined  — a diagnosis which has no revenue adjustment.



There will be a phase-in of the financial benefit over three years, so you won't see the revenue right away.  But experience teaches you should start submitting these codes now so you'll be ahead of the game---and be a winner.


Q&A with Dr. Tom

My compensation is not based on risk-coding. But I still get hassled about adding risk codes to my documentation. It takes a lot of extra time to deal with all the requests and I don't want to make my boss mad.

What should I do with all these requests?


Learn from the wisdom of Oprah


 "If you're going to tattoo "Welcome" on your forehead, people are going to wipe their feet on you."


So ignore those requests.


Take good care of your patients and flush the coding requests.

Those requests are not about compliance, they're about more revenue---revenue that you're not sharing in.


So when you're sent requests for documentation adjustments, either from your employer or from your insurer--- just delete them.


And if your medical director brings it up at your next review, nod politely and keep on with the ignoring.


Remember, your medical director is not your friend or colleague---she is an agent of your employer tasked with keeping your revenue up and your expenses down.



If they keep calling you on your efforts to control your time, identify to them what tasks you aren't doing and why you aren't doing it.


If the response is "this is no different than asking a surgeon to use a less expensive instrument. It's what we all have to do to keep the revenue flowing," then call them on it for the dishonest compliance tactic that it is.



The only way you're going to earn a reasonable return on your education, to not be treated like a cost center, is to be compensated with a portion of your Medicare Advantage revenue.


If you do it for free, they're not going to offer to pay you.

If you refuse, they may just make a compensation change.


But in the end, you just may need to find a new employer---one who doesn't see you as an expense but rather as a center of exceptional value for them and your patients.

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