From Dr. Tom's Desk

Last week we discussed a major implication of the release of the “Final Rule” of the prospective payment system for skilled nursing services.
 
Here’s another one.
 
Nursing homes are getting into the risk-coding business.
 
That’s right, the prospective payment system encourages nursing homes to take even greater pains to code every medical condition of their residents.
 
This makes it even simpler to care for these patients.
 
In the past, we’ve discussed trends in risk-coding nursing home patients here and here.
 
After reviewing the final rule, the upshot for you is this:
 
You can do very well taking care of nursing home patients simply by reducing their costs through delivering great care---you don’t have to worry about risk coding.
 
It makes a Medicare Advantage nursing home practice a no-brainer.
 
If nursing home patients aren’t part of your “portfolio of patients,” you’re missing out.

You Should Know

 
CMS has announced that Medicare Advantage plans can use step therapy when determining which outpatient medications they will pay for.
 
That’s right, your insurance partners will be able to dictate the choice of medication for given conditions---and your docs will have to justify any deviation.
 
It will create another layer of non-clinical work for your clinicians and increase your overhead as support personnel now will have another task.
 
Your tactic is simple.
 
Do better.
Twelve years ago, my partners and I were doing great under our Medicare Advantage contracts. Things were really humming.
 
Then, out of the blue, one of our insurance partners announced they were going to require prior authorizations on all imaging short of plain films.  It took less than a month for us to realize the true increase in overhead this would entail.
 
So, we made a call. One call to our insurance partner. We requested an exclusion for our patients.
 
“Oh, we didn’t mean it to apply to you,” was the response.
 
And everything went back to the way it was.  Why would they respond like that?  What made us so special?
 
We consistently gave them what they wanted.
 
Accelerating revenue growth.
 
We kept our Medical Loss Ratio low and the growth in our panels sizes high.
 
We made them more money year-after-year. They trusted us to keep our utilization down with our own tools.
 
One call--- and a wholesale change was the result. Imagine a small practice doing that with a fee-for-service contract.
 
That’s what you should do with these new medication step edits.
 
Do well. Give your insurance partner what they want. Demonstrate you can do so without these cost control tools.
 
Then ask for an exclusion.
 
There’s a good chance they’ll exempt your patients from the new regulations.
 
Imagine what would happen to your patient panel once word gets around that your patients don’t need to mess with prior auths to get their meds.
 
Success breeds success.
 
That’s Medicare Advantage in all its glory.

Tip From Tom

 
Under most Medicare Advantage contracts, physicians can admit patients directly to the nursing home without having to spend three acute days in the hospital.
 
With the right patient and the right facility, this can be a powerful tool to decrease your inpatient costs.
Can telemedicine fill the gap when Samantha loses her doctor?  She learns more than she bargains for trying to keep her family safe. Share her journey.

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