From Tom's Desk


Provider Directories Getting Worse


A newly released Federal study lends urgency to a recommendation I made in this space four months ago.


The message is clear.



Improve the accuracy of your physician network information---or else.



Physician network accuracy has been of increasing concern to CMS. They've recently identified the issue as a significant point of emphasis in its latest quality push.



Indeed, one doesn't have to read too far between the lines of CMS' recent updates to realize that the Federal Government is getting an increasing number of complaints about the misrepresentation of physician panels by insurers---and they are deadly serious about improving the status quo.



Beneficiaries are getting the bait and switch---thinking they're signing up with insurances that will cover their chosen doctors, and then realizing too late that it's not the case.



CMS has been issuing advisories about the problem, even to the point of threatening to include network accuracy as a STAR quality measure.



The result?



According to the report referred to above, the problem is getting worse, much worse---not better.



If your organization is looking for a low-hanging fruit, an easy win to get ahead of the curve--- Then improving the accuracy of your physician directory is the way to go.



So do it now, before not making changes really begins to really hurt.


You Should Know...


Lessons From United's Court "Win"

The compliance world is buzzing about the partial dismissal by a Federal judge of the qui tam action United States ex rel. Benjamin Poehling v. Unitedhealth Group, Inc et al.



Here's what you need to know.



The massive, multibillion-dollar case hinged on two key allegations; the defendant knowingly submitted false risk-codes and did not return money for previously submitted risk codes they knew to be false.



It's an enormous case with enormous implications.



It will set the tone for risk code enforcement for the next decade.



The judge dismissed the claims associated with the first set of allegations, though the door for an amended complaint was left open.



The action associated with the second was allowed to proceed.  It's still a 9-to-10 figure claim.



Your lesson?


If you're going to audit your risk-code submissions, then return the money you identify as inaccurately paid.


By statute, you only have a few weeks to do so.


This might seem self-evident, but if someone like United allegedly isn't doing so many other organizations probably aren't either.


So make sure your workflows include follow-through---all the way to returning any inappropriate payments.


In this case, the result of not doing so might be an enormous clawback and potential criminal charges.



All because one employee figured out what was going on, gathered evidence and obtained representation.


For a large insurer, such compliance actions may simply be considered the cost of doing business.


For someone even a little bit smaller, they might change your life---and very much for the worst



High-Value Insight


Recipe for Success

For almost a year, fifty full issues, I've been sharing little secrets to my incredible success with Medicare Advantage.



Hard-learned tactics that I learned from 20 years of working one of the first total-risk medicare advantage contracts ever.




Tips that lead me to be able to care for my patients in the way I thought best, despite an environment of increasing uniformity and restriction.



Tips that allowed me to practice with joy and longevity.



Here's a summary of those fifty tips:



  1. Collect a panel of patients---at least a hundred, usually no more than 500, certainly never more than 700.
  2. Accurately represent their disease burden through appropriate risk-code documentation and submission---with special attention to the ones only you, their personal physician can capture.
  3. Earn a trusting relationship with your patients. Customize their care through collaboration---and when they need access to the healthcare system, use your clout and prestige to optimize its delivery.



That's it.



Oh, I did forget one thing.



Heal with joy.


Q&A with Dr. Tom

In your book, you talk a lot about the value of hospice services, but they don't seem to be doing a lot to reduce my costs.  What am I doing wrong?



The value in hospice is not the destination, it's the journey.


Many venture capitalist firms are purchasing hospice systems, seeking to ride the demographic wave of an aging population to business success---including using data extraction techniques to identify potential "customers".


They are deluded.



You've probably seen this in your own organization.  A person's proprietary "risk" score hits a certain number and the palliative care physician, who the patient has never met, comes out and has an end of life discussion with him or her.  Maybe she even gets him to sign up.



Then the patient gets sicker, calls the ambulance, decides on one more procedure and, despite enrollment in hospice, the medical treadmill resumes its run.


It's clear the patient has signed up for hospice---and equally clear he hasn't signed on.


But . . .


Take that same patient. Get him through some hard times. Be there for him



Create a trusted relationship.



And bring up end of life care gradually in a safe environment.


Then sign him up for hospice.


It's a different deal----completely.



The lesson here?



There are no shortcuts.



Apply the lessons you instinctively know.  Create a bond, create a connection.


Discuss end of life care as appropriate



And hospice will be a tool of immense value.



To all concerned.




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