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Managed Care Backlash?

A True “Sea-Change”

By Dr. David Edward Marcinko; MBA, CMP

Publisher-in-Chief 

Does anyone recall a study several years ago by The MEDSTAT Group and JD Power and Associates, which surveyed nearly 30,000 physicians – participating in 150 healthcare plans and located in 22 different markets – nearly seven of ten physicians considered themselves “anti-managed care” with capitation accounts declining in nearly every HMO category. 

Of course, dis-satisfaction with financial reimbursement was the leading factor back then; but 4 other major factors drive physician’s rating of health plans now, as listed below: 

  • Satisfaction with financial reimbursement
  • Administration
  • Policies impacting on care quality
  • Support of clinical practice
  • Limits on medical care

Nevertheless, HMOs had not been initially unresponsive to this managed care backlash. 

For example, since 1998, managed care companies and their allies fought against restrictive new proposed regulations and spent more than $112,000 per lawmaker to lobby Congress.

This 60 million dollar outlay was four times the $14 million plus spent by medical organizations, trial lawyers ($1 million), unions ($1.4 million) and consumer groups ($8 million) to press for passage of the failed Patients Bill of Rights.

The $60 million dollar lobbying tab is also 50 percent higher than the $40 million dollars that tobacco interests spent to kill legislature to raise cigarette taxes to curb teenage smoking! 

But, there have been some recent physician victories.  

For example, the Independence Blue Cross (IBC) and the Pennsylvania Orthopedic Society agreed to settle a class action lawsuit about its payment policies, in July 2003, with payouts in 2004. Members of the class were to receive benefits worth an estimated $40 million, but more importantly, IBC was to disclose its standard fee schedules, changes applicable to provider’s specialty, and policies that may have effected reimbursement.  IBC also replaced its independent procedure designation with Current Procedure Terminology’s (CPT’s) separate procedure designation, and was to process claims in accordance with established standards.

Finally, the insurance company will establish a formal resolution process for provider payments appeals.  

Current and newly defunct IBC subsidiaries include QCC Insurance Company, Keystone Health Plan East, Amerihealth HMO, Amerihealth, Amerihealth HMO New Jersey, or Amerihealth New Jersey. 

Can you report a victory to our readers, in your own case?

Is this a sea-change, or merely an isolated event?

Reporting Healthcare Fraud and Abuse

Patient Bounty Hunters 

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief 

Fraud and Abuse Reporting Incentives 

Under the Health Insurance Portability Accountability Act, the Department of Health and Human Service (HHS) has operated an “Incentive Program for Fraud and Abuse Information”, since January 1999. 

In this program, HHS pays $100-$1,000 to Medicare recipients who report abuse in the program. To assist patients in spotting fraud, CMS has published examples of potential fraud, which include: 

  • Medical services not provided
  • Duplicate services or procedures
  • More expenses services or procedures than provided (upcoding/billing).
  • Misused Medicare cards and numbers
  • Medical telemarketing scams
  • Non-medical necessity.

And, there is no question that real fraud exists.

For example, the Office of Inspector General of the Department of Health and Human Services (HHS) saved American taxpayers a record $21 billion in Fiscal-Year 2003-04, according to former Inspector General Janet Rehnquist. 

Savings were achieved through an intensive and continuing crackdown on waste, fraud and abuse in Medicare and over 300 other programs for which the Office of Inspector General. (OIG) had oversight responsibility.

At last report, the agency performed or oversaw 2,372 audits, conducted 70 evaluations of department programs, and opened 1,654 new civil and criminal cases, bringing to more than 2,700 the number of active OIG investigations. 

Additionally, the OIG excluded 3,448 individuals and entities from participation in Medicare, Medicaid and other federally sponsored health care programs, and its enforcement efforts resulted in 517 criminal convictions and 236 successful civil actions. 

To discourage flagrant allegations, regulations require that reported information must directly contribute to monetary recovery for activities not already under investigation.

Nevertheless, expect a further erosion of patient confidence, as they begin to view healthcare providers in the same light as “bounty hunters”. 

Doctors – has a patient “turned-you-in” needlessly – yet?

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Concierge Medicine – New Wave or Drought?

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Boutique Medical Practices – Wave of the Future or Mirage?

[By Dr. David Edward Marcinko; MBA, CMP™]dr-david-marcinko1

Briefly, a new-wave boutique, or concierge medical practice business model requires an annual retainer fee for personalized treatment that includes amenities far beyond those offered in the typical practice. And, as doctors may not accept Medicare patients for two years thereafter, there is no going back to the economic oasis if the model doesn’t pan out.

Rather, patients pay annual out-of-pocket fees for top tier service, but also use traditional health insurance to cover allowable expenses, such as inpatient hospital stays, outpatient diagnostics and care, and basic tests and physician exams.   

Typical annual fees can range from $1,000 to $ 5,000 per patient, to family fees that top $20,000 a year, or more.  The concept, initially developed for busy corporate executives, has now made its way to those desiring such service; but the masses have been slow to accept the new business model. 

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Medical Malpractice – Hope Springs?

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The Medical Malpractice Insurance Crisis 

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief, FA and Health Insurance Agent]

DEM @ WhartonHas the Corner Been Turned?

In the fall of 2003, the American Medical Association announced that six more states had reached a medical malpractice crisis, with patients losing access to care due to physician attrition. The AMA’s list of crisis states then totaled 18.

The new states were: Arkansas, Connecticut, Illinois, Kentucky, Missouri and North Carolina. The 12 states previously identified are: Florida, Georgia, Mississippi, Nevada, New Jersey, New York, Ohio, Oregon, Pennsylvania, Texas, Washington and West Virginia.

More recently, the Medical Group Management Association (MGMA) reported that medical malpractice premiums for its members increased by more than 53% between 2003 and 2004. Today, about 25% of those physicians planned to retire, relocate or restrict their services over the next few years. Massachusetts was especially hard hit in 2003-06, as the practice environment worsened for the twelfth consecutive year, driven primarily by rising premiums for medical malpractice coverage. 

Yet, in 2007, the rate of medical malpractice claims fell for the fourth straight year in Pennsylvania, with half the payout of 2003. That suggests that claims are getting smaller, as observer’s credit a 2002 law which banned attorneys from moving cases to counties they felt would have more favorable juries. Now, the state’s physicians would like to see the state enact caps on non-economic damages. 

So, how is this crisis affecting you; if at all?

Spring 2011 - NIH

PPMC Redux

Physician Practice Management Corporations

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]dem21

Here Come the PPMCs … again, Maybe!

The Physician Practice Management Corporation (PPMC), left for dead by the year 1999, may make a comeback going forward in 2008.

PPMC are evolving from first generation multi-specialty national concerns, to second generation regional single specialty groups, to third generation regional concerns, and now to fourth and fifth generation Internet enabled service companies, providing both business to business solutions to affiliated medical practices, as well as business to consumer health solutions to plan members. 

Even survivors like Pediatrix Medical Group saw its stock drop was floundering following disclosure that federal officials were investigating its Medicaid billing practices a few years ago. 

On the other hand, many private medical practices were bought back by the same physicians that sold out to the PPMCs originally.

But, if an entity is being bought back and accounts receivable is being purchased, be careful not to pick this item up as income twice.  The costs can be immense to your medical practice 

Example: 

A family practice purchased itself back from a PPMC.  Part of the mandatory purchase price, approximately $200,000 (the approximate net realizable value of the accounts receivable), was paid to the PPMC to buy back accounts receivable generated by the physicians buying back their practice.   

Unfortunately, the physician-executive unknowingly began recording the cash receipts specifically attributable to the purchased accounts receivable as patient fee income.  If left uncorrected, this error could have incorrectly added $200,000 in income to this practice and cost it (a C Corporation) approximately $70,000 in additional income tax ($200,000 in fees x 35% tax rate).

The error in the above example is that the PPMC must record the portion of the purchase price it received for the accounts receivable as patient fee income.  The buyer practice has merely traded one asset, cash, for another asset, the accounts receivable.  When the practice collects these particular receivables, the credit is applied against the purchased accounts receivable (an asset), rather than to patient fees.

So, be careful out there! www.MedicalBusinessAdvisors.com

Assessment: Anyone burned in a similar manner?

PPMC Update 2019

***

The Hospitalists [Evolved]

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Whither the Hospitalists? 

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief] 

New Role also includes Hospital Based Medical Groups 

The usual role of inpatient care in this country, for many decades, saw hospitalized patients cared for by their primary care doctor or admitting physician. 

Although this model had the advantage of continuity, and perhaps personalization, it often suffered because of the limited knowledge base of the physician, as well as familiarity with the available internal and external resources of the hospital.  Furthermore, the limited time spent with each individual patient prevented the physician from becoming the quality leader in this setting.

These shortcomings have led hundreds of hospitals around the country to turn to the hospitalists as dedicated inpatient specialists. The National Association of Inpatient Physicians (NAIP) estimates the model could result in up to 50,000 hospitalists by the Year 2008. The term hospitalist was coined by Dr. Robert M. Wachter of the University of California at San Francisco. It denotes a specialist in inpatient medicine (personal communication). 

At its center is the concept of low cost and comprehensive broad based care in the hospital, hospice or even extended care setting. If, well designed, hospitalist programs can offer benefits beyond the often cited inpatient efficiencies they bring.

For example, the average length of stay for patients on the medical service of UCSF’s Moffitt-Long Hospital initially fell by 15%, compared to historical controls adjusted for case mix. There was no reported decrease in patient satisfaction or clinical outcomes. 

Similarly, another integration model is “on-site” employee affiliations that represent an adjustment of the hospitalist concept. This redeployment of existing MDs into the workplace (factory, police station, office building) or retail setting (Walmart, Intel Corp, Microsoft, IBM etc) is another exciting challenge in heath care today.

The keys to success are thoughtful implementation and a commitment to measure the results of change and use the data to produce further innovations. 

***

Hospital

***

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Beware “Faux” Health Insurance Models

 

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The Proliferation of Fraudulent Silent (“Mirror”) Healthcare Models – Should I Join?

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chiefdem2]

Beware the Silence 

A silent, faux, or “mirror” PPO, HMO or other provider model is not a formal managed care organization.  Rather, it usually is simply an intermediary attempt to negotiate practitioner fees downward by promising a higher volume of patients in exchange for the discounted fee structure.

Of course, the intermediary then resells the packaged contract product to any willing insurance company or other payer, thereby pocketing the difference as a nice profit. And, sometimes these virtual organizations are just indemnity companies in disguise.

Physicians should not fall for this ploy, since pricing pressure will be forced even lower in your next round of “real” PPO negotiations! 

Occasionally, an insurer or bold insurance agent will enter a market and tell its practitioners that they have signed up all the local, or many major, employers. Then, they’ll go to the employers and give them the same story about signing up all the major providers. The true story is that they haven’t signed up either and a Ponzi like situation is created!  

As an active fiduciary Certified Medical Planner™, insurance agent and licensed medical provider, I urge you to be on guard for silent HMOs, MCOs and any other silent insurance variation, since these virtual organizations may not exist except as exploitable arbitrage situations for the middleman. 

So, has anyone been duped out there?

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