From Tom's Desk

Underserved Populations a Winner

It's happening.


You've probably noted by now that caring for the underserved can be a big winner under a Medicare Advantage contract.

They tend to live in urban areas---and urban areas have much higher capitations rates.


And as we've discussed in this space before, risk-code calculations are being shifted to divert more resources to this population at the expense of others.


Medicare Advantage Organizations have recognized this---and you should see some of the "Special Needs Plans" that have been released in response.


Tailored to the Medicare/Medicaid population, they offer a suite of extra benefits to attract beneficiaries and help their primes keep them healthy.


Used properly, these plans should be rocket fuel for any value-based plan.


The revenues can help to fund ethnically matched providers in urban areas, increase the economic activity around health centers, and increase the social capital that only "similar other" professionals in their own community can generate---it truly is a win for everybody.


If you haven't checked out these newly released plans, do so right away.  You may change your strategic plans.


And if you're an insurer, make it a point to share them directly with your providers---especially the primes.


The payoffs---for everyone---will be enormous.


 

You Should Know...

Medicare Advantage and "Low Performing SNFs"

A recently published study suggests that earlier in this decade at least, Medicare Advantage beneficiaries with skilled needs were more likely to be cared for in lower quality skilled nursing facilities (SNFs) compared to beneficiaries enrolled in traditional Medicare.

The study has its limitations but it's making the rounds among your potential customers.

You need to make absolutely clear to them that, under the Medicare Advantage program, it's in everyone's interest that beneficiaries receive only the highest quality care.

And if you have contracts with SNFs based on a low per diem rather than quality and their willingness to collaborate with you---change them now.

They will cost you much more in the long run.

Fortunately, there's a book on how to use SNFs to your best advantage in your Medicare Advantage population.

I suggest you read it now.

High-Value Insight

Hierarchical Codes 

One Thing You DON'T Have to Worry About

There are some conditions that, when present in the same patient at the same time, give an additional risk modifier and, from that, additional revenue.

Congestive heart failure, COPD and chronic kidney disease each individually result in a higher risk score.

If one patient has all three, not only is the patient credited with the risk associated with each condition individually, they also get an extra boost from the combination.

A revenue bonus if you will.


Learning about this can be quite confusing---and lead to anxiety that you may somehow be missing out on revenue.

Here's a high-value tip---don't worry about them.

Some health systems and insurers go crazy trying to capture the last risk code to complete the set.

Ignore them.

Such strategies result in over-coding and revenue that's at great risk for clawbacks.

Spend your time and effort coding accurately and don't worry about these combinations.

They'll take care of themselves

Q&A with Dr. Tom

There's no part of my compensation that's based on the financial performance of my Medicare Advantage patients.  Yet I'm constantly pestered about improving my coding and care costs.  There's more and more hoops I have to jump through to get care for these patients.  My inbox is full of recommendations to addend my already closed office notes.

It's taking up A LOT of my time and I'm seeing fewer patients because of it.

What should I do?

Quit.  Now.

Shared-risk contracting under Medicare Advantage gives you a chance to get paid based on your skill and expertise.

Without participation in your Medicare Advantage contract, you're a tool, a commodity---and you'll be treated as such.

You and your personal time will be squeezed and squeezed and squeezed again until you've had enough.

Then they'll bring some young sucker in to replace you.

Lather. Rinse. Repeat.

You'll be just like a turn of the century factory worker, working the looms of some sweatshop without the protection of a union---used and then discarded when no further profit can be wrung from your broken body.

Think that's harsh?  Look around at your fellow clinicians.

If you can't quit, then just say no to your employer.

No, I'm not going to spend extra time risk coding---I'm not getting paid for it.

No, I'm not going to spend my time jumping through your cost-control hoops---I'm not getting paid for it.

But if you do this, better be prepared to be put on the dreaded "Performance Improvement Plan"---a black mark that'll follow you around for the rest of your life.

Better to just quit---and find an employer with a clue, an a soul.

You deserve better.


In fact---you deserve the best!