PODCAST: “Signify Health” Start-Up Risk Adjustments [Medicare Advantage Part C]

BY ERIC BRICKER MD

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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FINANCIAL PLANNING: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

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PODCAST: APPEALS of Medicare Advantage [Part C] Plans

BY CMS

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PODCAST: Medicare Advantage [PART C] Cost Reduction Strategies

BY ERIC BRICKER MD

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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INTERVIEW: A Solution for Healthcare Financing?

HEALTHCARE FINANCING

Former: CEO and Founder
Superior Consultant Company, Inc.
[SUPC-NASD]

EDITOR’S NOTE: I first met Rich in B-school, when I was a student, back in the day. He was the Founder and CEO of Superior Consultant Holdings Corp. Rich graciously wrote the Foreword to one of my first textbooks on financial planning for physicians and healthcare professionals. Today, Rich is a successful entrepreneur in the technology, health and finance space.

-Dr. David E. Marcinko MBA CMP®

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Staff & Contributors - CHAMPIONS OF WAYNE

By Richard Helppie

Today for your consideration – How to fix the healthcare financing methods in the United States?

I use the term “methods” because calling what we do now a “system” is inaccurate. I also focus on healthcare financing, because in terms of healthcare delivery, there is no better place in the world than the USA in terms of supply and innovation for medical diagnosis and treatment. Similarly, I use the term healthcare financing to differentiate from healthcare insurance – because insurance without supply is an empty promise.

This is a straightforward, 4-part plan. It is uniquely American and will at last extend coverage to every US citizen while not hampering the innovation and robust supply that we have today. As this is about a Common Bridge and not about ideology or dogma, there will no doubt be aspects of this proposal that every individual will have difficulty with. However, on balance, I believe it is the most fair and equitable way to resolve the impasse on healthcare funding . . . .

CITE: https://www.r2library.com/Resource/Title/0826102549

Let me start in an area sure to raise the ire of a few. And that is, we have to start with eliminating the methods that are in place today. The first is the outdated notion that healthcare insurance is tied to one’s work, and the second is that there are overlapping and competing tax-supported bureaucracies to administer that area of healthcare finance.

Step 1 is to break the link between employment and health insurance. Fastest way to do that is simply tax the cost of benefits for the compensation that it is. This is how company cars, big life insurance policies and other fringe benefits were trimmed. Eliminating the tax-favored treatment of employer-provided healthcare is the single most important change that should be made.

Yes, you will hear arguments that this is an efficient market with satisfied customers. However, upon examination, it is highly risky, unfair, and frankly out of step with today’s job market.

Employer provided health insurance is an artifact from the 1940’s as an answer to wage freezes – an employer could not give a wage increase, but could offer benefits that weren’t taxed. It makes no sense today for a variety of reasons. Here are a few:

1. Its patently unfair. Two people living in the same apartment building, each making the same income and each have employer provided health insurance. Chris in unit 21 has a generous health plan that would be worth $25,000 each year. Pays zero tax on that compensation. Pat, in unit 42 has a skimpy plan with a narrow network, big deductibles and hefty co-pays. The play is worth $9,000 each year. Pat pays zero tax.

3. The insurance pools kick out the aged. Once one becomes too old to work, they are out of the employer plan and on to the retirement plan or over to the taxpayers (Medicare).

4. The structure is a bad fit. Health insurance and healthy living are longitudinal needs over a long period of time. In a time when people change careers and jobs frequently, or are in the gig economy, they are not any one place long enough for the insurance to work like insurance.

5. Creates perverse incentives. The incentives are weighted to have employers not have their work force meet the standards of employees so they don’t have to pay for the health insurance. Witness latest news in California with Uber and Lyft.

6. Incentives to deny claims abound. There is little incentive to serve the subscriber/patient since the likelihood the employer will shop the plan or the employee will change jobs means that stringing out a claim approval is a profitable exercise.

7. Employers have difficulty as purchasers. An employer large enough to supply health insurance has a diverse set of health insurance needs in their work force. They pay a lot of money and their work force is still not 100% happy.

Net of it, health insurance tied to work has outlived its usefulness. Time to end the tax-favored treatment of employer-based insurance. If an employer wants to provide health insurance, they can do it, but the value of that insurance is reflected in the taxable W-2 wages – now Pat and Chris will be treated equally.

Step 2 is to consolidate the multiple tax-supported bureaus that supply healthcare. Relieve the citizens from having to prove they are old enough, disabled enough, impoverished enough, young enough. Combine Medicare, Medicaid, CHIP, Tricare and even possibly the VA into a single bureaucracy. Every American Citizen gets this broad coverage at some level. Everyone pays something into the system – start at $20 a year, and then perhaps an income-adjusted escalator that would charge the most wealthy up to $75,000. Collect the money with a line on Form 1040.

I have not done the exact math. However, removing the process to prove eligibility and having one versus many bureaucracies has to generate savings. Are you a US Citizen? Yes, then here is your base insurance. Like every other nationalized system, one can expect longer waits, fewer referrals to a specialist, and less innovation. These centralized systems all squeeze supply of healthcare services to keep their spend down. The reports extolling their efficiencies come from the people whose livelihoods depend on the centralized system. However, at least everyone gets something. And, for life threatening health conditions, by and large the centralized systems do a decent job. With everyone covered, the fear of medical bankruptcy evaporates. The fear of being out of work and losing healthcare when one needs it most is gone.

So if you are a free market absolutist, then the reduction of vast bureaucracies should be attractive – no need for eligibility requirements (old enough, etc.) and a single administration which is both more efficient, more equitable (everyone gets the same thing). And there remains a private market (more on this in step 3) For those who detest private insurance companies a portion of that market just went away. There is less incentive to purchase a private plan. And for everyone’s sense of fairness, the national plan is funded on ability to pay. Bearing in mind that everyone has to pay something. Less bureaucracies. Everyone in it together. Funded on ability to pay.

Step 3 is to allow and even encourage a robust market for health insurance above and beyond the national plan – If people want to purchase more health insurance, then they have the ability to do so. Which increases supply, relieves burden on the tax-supported system, aligns the US with other countries, provides an alternative to medical tourism (and the associated health spend in our country) and offers a bit of competition to the otherwise monopolistic government plan.

Its not a new concept, in many respects it is like the widely popular Medigap plans that supplement what Medicare does not cover.

No one is forced to make that purchase. Other counties’ experience shows that those who choose to purchase private coverage over and above a national plan often cite faster access, more choice, innovation, or services outside the universal system, e.g., a woman who chooses to have mammography at an early age or with more frequency than the national plan might allow.  If the insurance provider can offer a good value to the price, then they will sell insurance. If they can deliver that value for more than their costs, then they create a profit. Owners of the company, who risk their capital in creating the business may earn a return.

For those of you who favor a free market, the choices are available. There will be necessary regulation to prevent discrimination on genetics, pre-existing conditions, and the like. Buy the type of plan that makes you feel secure – just as one purchases automobile and life insurance.For those who are supremely confident in the absolute performance of a centralized system to support 300+ million Americans in the way each would want, they should like this plan as well – because if the national plan is meeting all needs and no one wants perhaps faster services, then few will purchase the private insurance and the issuers will not have a business. Free choice. More health insurance for those who want it. Competition keeps both national and private plans seeking to better themselves.

Step 4 would be to Permit Access to Medicare Part D to every US Citizen, Immediately

One of the bright spots in the US Healthcare Financing Method is Medicare Part D, which provides prescription drug coverage to seniors. It is running at 95% subscriber satisfaction and about 40% below cost projections.

Subscribers choose from a wide variety of plans offered by private insurance companies. There are differences in formularies, co-pays, deductibles and premiums.

So there you have it, a four part plan that would maintain or increase the supply of healthcare services, universal insurance coverage, market competition, and lower costs. Its not perfect but I believe a vast improvement over what exists today. To recap:

1. Break the link between employment and healthcare insurance coverage, by taxing the benefits as the compensation they are.

2. Establish a single, universal plan that covers all US citizens paid for via personal income taxes on an ability-to-pay basis.  Eliminate all the other tax-funded plans in favor of this new one.

3. For those who want it, private, supplemental insurance to the national system, ala major industrialized nations.

4. Open Medicare Part D (prescription drugs) to every US citizen. Today.

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Waived Co-Pays for United Healthcare Medicare Advantage Plans

Waived Co-Pays for United Healthcare Medicare Advantage Plans

By Jessica M. Wade, MHA, Practice Manager

Just to clarify, the UHC copay waiver info is listed  clearly on the UHC website as follows:
“Members will have a $0 copay for covered primary care provider (PCP) and specialist physician services, as well as other covered services (listed below) between May 11, 2020 until September 30, 2020″. By lowering our PCP and specialist copays to $0, along with our telehealth cost-share waiver, we hope to help make it easier for you to access care”

Services included

The following services, if covered by your plan, are eligible for a $0 copay under the cost-share waiver, but do not include diagnostic tests and certain other services.

• Primary care provider (PCP) office visits
• Specialist physician office visits
• Physician assistant or nurse practitioner office visits
• Medicare-covered chiropractic and acupuncture services
• Medical and Podiatry services and routine eye and hearing exams
• Physical therapy, occupational therapy and speech therapy
• Cardiac and pulmonary rehabilitation services
• Outpatient mental health and substance abuse visits
• Opioid treatment services

The $0 copay applies to services from a network provider and out-of-network services covered by the plan. Member cost-share is not waived for the
following services, unless they are related to COVID-19 testing or treatments:

• Lab and Diagnostic tests (radiological and non-radiological)
• Part B and Part D drugs
• Durable Medical Equipment, Prosthetics, Orthotics and Supplies
• Renal Dialysis
• Other services not covered by your plan

Co-pays, co-insurance and deductibles for services in the following settings are not waived. Members will be responsible for their share of the cost under their benefit:• Inpatient hospital and Outpatient surgery or observation services.

• Skilled Nursing Facilities
• Emergency, Urgent and Ambulance services

Source: https://www.uhc.com/health-and-wellness/health-topics/covid-19/coverage-and-resources/cost-sharing-waived

Furthermore, reimbursement is based on the Medicare fee schedule as these plans waiving copay are Medicare Advantage plans and subject
to Medicare guidelines and reimbursement models.

THANK YOU

 

On Medicare Advantage Plan[s] Enrollment

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Medicare Pre-Paid Enrollee Composition

By http://www.MCOL.com

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medicare advantage

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NOTE: CMS Releases 2013 Hospital, Physician Data

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The opening of this week’s Health Datapalooza conference in Washington was the setting for a new Medicare data dump on physician and hospital inpatient/outpatient payment and utilization rates. This is the third annual release of data as part of the Obama administration’s information transparency initiative to promote increased quality of care and more informed healthcare spending by consumers. A link to the inpatient dataset is here, the outpatient dataset is here, and the physician / supplier dataset is here.

Source: Joseph Goedert, Health Data Management [6/2/15]

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Conclusion

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Update on the Medicare Oriented Universe

October Plan Management Navigator 

By Douglas B. Sherlock; MBA, CFAStetho-Claim

Please find attached the October 2009 edition of our Plan Management Navigator.

Medicare-Orientated Universe

In this month’s edition, we update ME-P and all readers on the results for the Medicare-Oriented universe, and provide summary functional area breakouts as well as expense trends. Holding constant the universe, and the product mix offered, administrative expense growth was higher than last year.

For example, eleven Medicare-Oriented plans serving 1.1 million beneficiaries participated in this year’s benchmarking study. In addition, the results from Blue Cross Blue Shield Plans and Independent / Provider-Sponsored Plans are also summarized. With these additional plans, we provide selected information on health plans serving 2.1 million Medicare beneficiaries, comprising approximately 22% of Medicare Advantage members during 2008.

Assessment

The analysis is based on materials from our Sherlock Expense Evaluation Report (SEER) for the Medicare-Oriented Plans. Additional information about SEER is available at www.sherlockco.com/seer.shtml or by contacting me.

Link: Navigator 10-09 

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Understanding Periodic or New Employee Practice Compliance Audits

Perform and Improve as Needed

By Patricia Trites MPA, CHBC; with Staff Reporters 

www.HealthcareFinancials.comho-journal12

There are several types of compliance audits that a medical practice, clinic or healthcare organization might need to perform. The starting point, discussed elsewhere on this ME-P, is to obtain a baseline audit. The next step is periodic audits or reviews that are performed after information is obtained from the baseline audit.

Periodic Audits

Periodic audits are performed on an on-going basis. Depending on the volume of billing, these may occur weekly for a large multi-specialty ambulatory clinic to quarterly for a small medical practice. These periodic audits can be random or scheduled. Sometimes in the process of seeing how things run, a surprise review can be informative to staff and practitioners.

New Employee Audits

New employees require regular training and reviews until there is confidence in their capabilities. Background checks are often helpful to find out whether there are any potential conflicts. In hospitals, health plan offices, surgery centers, and other regulated facilities, background checks are a normal part of the credentialing process. This process typically includes Medicare violations, which would show up on the National Practitioner Data Bank report. However, independent medical practices do not have access to this type of information and may have to rely on other organizations to obtain the information. The OIG and the General Services Administration both maintain a database of excluded persons and entities that can be accessed through the Internet. As part of the organization’s initial and periodic audits, queries of these two databases should be performed for all employees and independent contractors (like locum tenens physicians). Failure to do so can put the practice at risk of large civil money penalties ($10,000 for each occurrence) and liability for refunds of all claims the excluded individual had part in providing or billing.

Assessment

Additional audits can be performed whenever new employees are added, or if there are complaints or issues that arise in the course of business; prn.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated? What interesting, informative or strange tidbits have you uncovered in your auditing processes?

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Obama on the SGR Physician Payment Formula

Solo Doctors and and Small Group Practices May Benefit

By Staff Reporterscoins3

According to Diana Manos of Healthcare Finance News, on March 23, 2009, small medical group practices and solo and/or independent physicians may benefit most from the recently proposed Obama healthcare budget. In it, President Obama asked Congress for $76.8 billion for the Department of Health and Human Services [DHHS] for fiscal year 2010. Some funding would come from changes to the way healthcare is provided, with a new emphasis on pay-for-performance [P4P] for Medicare providers.

The AMA’s Response   

It was reported that, Joseph M. Heyman, MD, chairman of the American Medical Association’s Board of Trustees, said the AMA is pleased with the administration’s proposed new baseline – or projected spending over a period of time – or Medicare physician payment updates.

“Unlike previous budget forecasts, the administration’s new budget baseline recognizes that Congress needs to and will act to avert the serious access crisis that looms as physicians face drastic payment cuts in the coming decade due to the failed Medicare physician payment formula,” he is reported to have said. Furthermore,  

“The AMA strongly supports the use of a realistic baseline as a foundation for Congress to move forward with a permanent solution to the flawed SGR physician payment formula, and urges the committee and Congress to ensure that a new Medicare physician payment baseline is adopted in the 2010 Fiscal Year (FY) Budget Resolution.”

Assessment

Under the president’s budget request, Medicare Advantage would be revamped; physicians and hospitals could expect to be paid for performance [P4P] under Medicare; pharmaceutical companies would face steeper competition from generic drug companies and the government would clamp down on inadvertent and fraudulent overpayments under Medicare. The budget also calls for “comprehensive, but fiscally responsible reforms” to the physician payment formula [Sustainable Growth Rate], moving toward rewarding doctors for efficient quality care.

Link: http://www.healthcarefinancenews.com/news/small-physician-practices-can-expect-real-changes-healthcare-under-obama-budget

Conclusion

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Some Insight on Medicare Advantage Plans

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Enter the Bounty Hunter Insurance Agents

dem21

[By Dr. David Edward Marcinko; MBA]

[Publisher-in-Chief]

As a health insurance agent and industry insider for more than a decade, I know first hand that the agents and brokers who enroll senior citizens in Medicare Advantage (MA) plans often make more on those members than the health plans themselves. 

Example:

For example, up to $400-600 can be spent on an insurance agent/broker fee by the health plan, contributing to a total member acquisition cost that can exceed 10% of the premium dollar. And, this commission fee or bounty on “grandma” – much like a bulls-eye target on her back – was much higher back in the day. Hence, all the “free” seminars, luncheons, trinkets and other senior citizen freebies cloaked as information dissemination.

Acquisition Costs High

Even if Medicare Advantage plans could deliver the actual health care benefits at a considerably lower cost than traditional Medicare Fee for Service (FFS); it is very possible that the entire savings could be consumed by member acquisition costs.

Assessment

Now, as a doctor, insurance agent, financial advisor, health economist and future MC patient, I believe that traditional Medicare is a very tough act to follow; and is still the best deal around, by far. Now, try to convince my dad.

Conclusion

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