From Tom's Desk

CMS Directly Marketing Medicare Advantage to Beneficiaries---Why Fight it?

If your organization is considering using its ACO to take financial risk through the “Pathways to Success” program, know that the government is setting you up to fail.

ACO Shared Savings Programs are poorly designed to accept financial risk. The patients aren’t attributed to a specific prime, the comparison populations shift, the accounting is complex---the reasons go on and on.

It's clear that by transitioning ACOs into risk-taking structures, what the government really wants is to be done with ACOs completely.

Under ACO’s, the government still has the ultimate financial responsibility for the healthcare costs of its beneficiaries. It does not want this responsibility. It can’t pay for its promises. It wants private insurance to accept the financial risk.

I called this last year, when insiders from the past and current administrations started hopping on the boards of Medicare Advantage Organizations.  That's when the astute observer understood that at long last the Federal government was going all in on Medicare Advantage.

The trend continued earlier this year when, after decades of overt hostility,  the annual Medicare guide that goes out to tens of millions of beneficiaries endorsed Medicare Advantage as an option for their healthcare.

You don't have to believe me. Go online and compare the 2015 Medicare guide to the 2018 edition. The difference in tone is startling.


And this week we find that the Federal government is now reaching out directly to Medicare beneficiaries, recommending Medicare Advantage plans.

Unthinkable even 18 months ago.

Your lesson?


Don’t play the ACO game, it’s designed to fail. You will either understand that now, or after years of expensive and costly losses.

Go with the flow and go all in on your Medicare Advantage system.

The government has put the wind at your back.

All you need is to set sail.


You Should Know...

Provider Directories Fail Again---Here's How You Can Take Advantage

The private auditor that CMS engages to assess the accuracy of provider directories just reported that more than half had “significant errors.”

Wrong names, wrong addresses, wrong telephone numbers.


CMS has stated its concerns that inaccurate directories are being used by insurers to fraudulently sell benefit packages through representations that their networks include physicians which they in actuality do not.

This is the last audit before CMS decides what to do about it.

Based on these results, Medicare Advantage Organizations can expect serious financial consequences for continued high error rates---now in excess of 50%.  For whatever reason, insiders are telling me this issue is a major concern for CMS.

Your organization can stand out by vetting its own presence in the provider directories of the Medicare Advantage Organizations in which it participates. Make sure the docs who are supposed to be there, are there. And make sure their contact information is accurate.


The online version of these directories change all the time, so you’re going to have to check them at least every month.

If you don’t do it, much of your marketing effort will be for naught. 


What’s the point of advertising your services if, when a beneficiary is deciding whether to sign up, your doctor’s name isn’t on the list?

Or even worse, what if your physician is on the list of an insurance plan you don't take.  How much of your manpower time will be taken up addressing that error when the patient presents for a visit? (spoiler alert---a lot!)


However, if you do check regularly and make sure your medical staff is accurately represented, your marketing efforts will be multiplied many fold.



Tips From Tom

RAF Scores Can Be Too High

Although it’s possible, it’s rare for a clinician to consistently keep their risk-scores above 1.6 without cutting corners and submitting codes inappropriately. Single those clinicians out for special compliance screening. When compliance enforcement once again becomes an issue, and it will, they will be easy targets---and so will your revenue.

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