From Dr. Tom's Desk

Large healthcare consulting firms, even tech cross-overs such as Oracle, are getting involved in Medicare Advantage consulting.
Here’s a recent example of their work, “The Secrets to High-Performing Medicare Advantage Plans.”  Millions of dollars in the making, backed by marketing wizards and Ph.Ds. from our finest universities---and they get it exactly wrong.
Lots of boilerplate about “integrative technologies” and “staying ahead of regulatory changes.”
Very little useful information.
These consultants get gigs because their nameplate gives them credibility and their connections create results.  They don’t possess any special expertise, they are in the influence business.
The only influence I have is over your success.
Here’s the secrets to a high-performing Medicare Advantage program--free, from someone who creates them from the bottom-up and wants you to be similarly successful. I can help you implement them, I can mentor your physicians or you can take this information on its own and recreate my own nine-figure success.

  • Give you primes skin in the game
  • Educate them in the workings of their contract.
  • Mentor them for success
  • Grow their panels
  • Code up their patients
  • Give them great care 

That’s it.  No extra technology to buy, no hidden costs. Just unleash your medical staff and their skilled innovation on your organization’s Medicare Advantage patients and you’re off to the races.
Enjoy your success.

You Should Know

CMS’s “2014 Overpayment Rule” has been thrown out by the U.S. District Court in Washington D.C.
The 2014 rule established that Medicare Advantage Organizations (MAOs) have 60 days to return overpayment once they were identified by validation audits or be subject to all the sanctions of the False Claims Act.
The best detailed look at the reasoning behind throwing out the rule I’ve found is here.
But this newsletter is the only place you’ll get an explicit reading of the implications.
What are they?
As of right now, absent blatant fraud, there is no mechanism for recovering over-coding overpayments from MAOs. It sounds ridiculous, but it’s true.
CMS is going to have to completely redo its 2014 overpayment regulations.  And to satisfy the court, it’s going to have to do it in such a way as to be even more complex than it is now.
It’s hard to imagine any new rule is going to be enforced retroactively.
Your action is clear.
Follow the ICD-10 instructions guidelines and guidelines---but feel free to code aggressively.  Just don’t go crazy and submit codes for conditions that don’t exist or aren’t treated.
During this hiatus, no one is ever going to call you on aggressive coding.
Least of all your insurance partners. 
They’ll still do validation audits and keep up the appearance of compliance. They may even send back some self-identified overpayments to CMS. But it will be just for show.
Why is no one else giving you this interpretation of events?
Because when the burglar finds the bank vault isn’t locked at night, he’s unlikely to tell anyone.
I, on the other hand, will tell you exactly how it is.
So, code---ethically, accurately, but feel free to go right up to the line.
When the environment changes, I’ll let you know.

Tip From Tom

 “The more skin the primary care provider has in the game, the more efficient, cost-effective and sustainably profitable the Medicare Advantage contract.”
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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