From Tom's Desk


Lessons From the 2019 Draft Advanced Notice

The 2019 Draft Advanced Notice for Medicare Advantage is out.


And for Medicare Advantage geeks like myself, it's like Christmas in February.


The almost 200 pages are packed with data, surprises and tells for the future.


HEIDIS data exemptions for Puerto Rico?  It's in there (as I predicted last year).


ESRD HCC adjustments that continue to shift resources to the underserved?  It's in there.


Future trends in the "telehealth access" quality measure?  It's in there.


My personal analysis took 8 hours over two days and I've only scratched the surface.


The take home?


Don't let your clinicians see it.  Don't even let them know it exists.


It's so complex, so overwhelming that they will disengage in despair.




Find the 3-4 inflection points in your personal Medicare Advantage contract that will lead to the greatest ROI and hit them hard.


Educate your clinicians, ensure they have the resources to do well and reward them for doing so.


Leave all the other stuff to organizations with the resources to deal with them.


Worry about what you can have maximal impact on,  then push---hard.


And succeed.


You Should Know...

2019 Payment Increases Not All They Seem

The headline number in the Advanced Notice discussed above is a year-over-year increase in base payments for 2019 by 1.84% on average compared to the 0.45% plans received last year. 

Some estimate that the average payment rate for covered beneficiaries will increase by 3.1% once increases in coding intensity are included,  up from a 2.95% increase last year.

But don't be fooled.


That average is just that, an average.


What's not mentioned is that, once your patient's RAF score is calculated at the end of the year,  CMS is going to reduce it by 5.9%, right off the top.  This to adjust for the higher diagnostic risk code submissions for Medicare Advantage patients compared to similar beneficiaries enrolled in traditional Medicare. Last year the adjustment was not quite as bad---5.4%.


The upshot?


Medicare Advantage payments may be going up on average, but so is the over-coding adjustment. 


You must make sure you're capturing every chronic disease code you found last year---plus one more acute or new chronic disease code just to maintain your current level of revenue.


And if you haven't educated your clinicians, aligned your interests, shared your risk, good for you.

That's the easiest place to start.



High-Value Insight


Stand Out with a Get Acquainted Visit

It's so important to watch your patient panel list every month. 

That's how you identify patients new to your panel so you can invite them to come in and get to know you.


But sometimes they just won't come in.



They don't want to get sick, they don't want to spend the money, or they simply don't want to.


It can be a tough problem.  


I should know.  


I never was able to get more than 97% of new patients in during any given year.


That's pretty high, but I know those three percent cost me big money when they became ill and it took 18 months for their capitation to catch up and reflect their care costs


What to do?


Consider inviting recalcitrant new patients in for a "get acquainted visit" at a time convenient for them and at no charge.


Make it clear that the visit is simply to introduce them to the office, the staff, the workflows---to be able to take the time to thoroughly review and enter their medical history and other information into the electronic health record.


To give them a chance to just get to know you.


Make the time at their convenience, but also at a time, early or later, when you know there won't be many ill patients in your waiting room.


And make it clear that because of Medicare rules you won't be able to deliver any medical care, change or refill medications, they have to pay a co-pay for that---you just want to get to know them.


I found many of my resistant patients would jump at the chance to see the doctor for "free." At the very least they were be taken aback by this highly unusual offer.


But be careful.


To keep from getting in compliance trouble there are a few big "can nots"


  • You cannot offer anything of value to get them in. No money, no gifts, nothing.


  • You also can't pay their co-pays for them---that's a big no-no.


  • Don't prescribe or change any meds either.  That's for a formal visit. Again make this clear up front to set appropriate expectations.


  • And you can't submit any diagnostic codes for the encounter either.  This is a social visit, document what you did but bill nothing.


But what you have done is build rapport. You've let your new patient know that you and your staff are different. And you have a much better idea of their overall health status and what steps are needed to improve it.


Remember, it's your relationship with your patient that generates the true value in healthcare.


Invest in that, and you'll never go wrong.




Q&A with Dr. Tom

My employer is offering gifts and free raffle tickets to try to get our patients in to see their prime every year so they can get their risk codes submitted.


This seems fishy to me, is it ok?




Absolutely not.


What you describe is a "kickback"---and folks go to jail for offering them.


A "kickback" is an offer to a  beneficiary of something of value so they will use you to provide services that can be billed to the government.


It's never ok.

If you're in this position, and it's more common than you would think, ask your immediate supervisor why giving such gifts does not constitute a kickback.


Then ask for it in writing.


No luck?  Do the same with your compliance officer in your employer's coding department.


Still no luck?  Start keeping records.  When you get twenty or so, google "qui tam attorney" and contact them with your concerns.


Or find a new job.


If you see a patient who's been offered something of value just to come in, even if you're not the one doing the offering and even if you didn't do it intentionally, you've committed health care fraud.


Ask yourself, when someone does finally contact the feds and a head is demanded, who's going to take the fall? 


Who, at the least, is going to end up with a black mark on their record?


Your employer's leadership, your administrator or you?


Ask yourself that question.

And act accordingly.



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