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Introduction of the guest Matt Gibson from 90 Days from Retirement, a platform educating about insurance post-retirement.
Discussion about the prevalence of insurance agents buying leads of people turning 65 and how 90 Days from Retirement differs by providing education instead.
People turning 65 often receive unsolicited mail and phone calls offering help with Medicare, which can be overwhelming.
Explanation that data about people turning 65 is publicly available, and some businesses generate leads by buying and selling this data.
Mention of the lack of enforcement of rules against unsolicited phone calls to sell certain Medicare products.
Brief explanation of the main products sold by Matt's agency, including Medicare supplement plans also known as Medigap plans.
Medicare and Medigap: Medigap plans supplement Medicare by covering deductibles and co-insurance that Medicare doesn't cover. This is one path individuals can take when they start Medicare.
Medicare Advantage (Part C): Contrary to Medigap, Medicare Advantage acts as a replacement policy for Medicare. When someone signs up for a Medicare Advantage plan, their Medicare parts A and B are essentially turned off and the responsibility for payment and administration is transferred to the insurer. In exchange, Medicare pays the insurer a monthly fee.
Medicare Advantage Plan Payment: Most Advantage plans have zero monthly premium for the individual because the insurer receives payment from Medicare, which can be a substantial sum.
Becoming a Medicare Broker: To become a broker, one must be health insurance licensed, contract with specific insurance companies, and pass carrier-specific training and certification. The process can be time-consuming and complex.
Commission Structure: Brokers must contract with insurance companies to earn commission. The commission rates are standardized and set by CMS. They do not directly negotiate these commissions but rather work under the structures set by larger field marketing operations (FMOs).
Medicare Advantage (MA) plans and Part D drug plans are highly regulated, and insurance carriers cannot incentivize brokers to sell more products through bonuses or rewards.
When a broker facilitates the signup of a client for an MA plan, their name and broker ID number are included in the application (paper or electronic), enabling the insurance carrier to attribute the commission.
Brokers must be certified and part of the network of the plan they are selling. They can't start selling a plan for which they haven't taken certification.
The availability of MA plans varies by zip code, influenced by factors such as population and medical resources. Brokers are licensed by state and may not have access to marketing materials or sell plans in states where they are not licensed.
If a broker is certified with a limited number of MA plans available in a client's region, they are expected to inform the client about the existence of other plans, even if they don't earn a commission on them.
Brokers often have to narrow down the choice of plans based on the client's needs, including preferred doctors, medications, and hospital networks.
All telephonic or online consultations have to be recorded, and brokers are required to inform clients that they might not be licensed with every product in the area, even if they are.
There were approximately 60,000 complaints to Medicare from call centers in the previous year, likely because brokers were not fully representing all available products in their market.
Brokers use tools to compare the cost of medications across carriers and to search for doctors within each carrier's network. However, some carriers choose not to participate with certain tools, requiring brokers to go directly to the carrier's website.
The discussion involves health insurance, Medicare Advantage (MA) plans, and how insurance agents/brokers operate.
The speaker mentions a preference for checking a carrier's site when looking for doctors or dentists.
Agents often receive an upfront commission when clients sign up, followed by smaller, ongoing commissions for renewals.
After signing clients, the speaker’s office offers full service, assisting with claims, billing, and more. They provide quarterly newsletters and communicate regularly, especially during annual election periods.
If a client's MA plan is changing significantly, the agent may recommend exploring other options. However, if the plan remains largely the same, clients are advised to continue with it.
Not many clients switch from one MA plan to another, or from MA to original Medicare, or vice versa. Changes typically occur due to network alterations, alteration in benefits, or advertisements.
Switching from an MA plan to a supplement plan is not always easy and may involve health questions and underwriting. Outside of specific open enrollment windows, clients cannot switch.
Churn within the MA system does occur, though it doesn't benefit the speaker's agency financially to regularly switch clients' plans. Other agents, however, may benefit from such churn.
There is no cost to the consumer to work with an agent. Agents are also not allowed to buy meals or gifts for potential clients, though smaller items such as coffee or appetizers are permitted.
There is no underwriting process for MA plans. Once you have Medicare and live within the service area, you are eligible.
For more information or assistance, the speaker invites people to visit their website, 90daysfromretirement.com. -
Introduction of a new product called Aging Here newsletter
Request for subscriptions and feedback for Aging Here
Introduction of guest Dr. Marc Gruner from Limber Health (https://www.limberhealth.com/)
Marc's background as a physician and entrepreneur
Marc's involvement in creating new CPT codes for RTM
Introduction to Limber Health and its solution for improving therapy adherence
Explanation of how Limber's app helps monitor and track exercises at home
Importance of home exercise therapy for better outcomes
Potential for house calls in physical therapy
Challenges with traditional paper printouts for home exercises
Importance of creating a sustainable lifestyle of exercising at home
Average age of patients receiving remote therapeutic monitoring (RTM)
Problems solved by Limber: confusion, compliance, unnecessary surgeries, cost reduction
Frustration as a physician prescribing physical therapy
Barriers to successful therapy: cost, time, travel
Need for codes to support RTM model
Involvement in the development of new RTM codes
Importance of a good business model for providers
Collaboration with AMA and other stakeholders to develop new codes
Importance of filling out forms and persevering through the process
Overview of the process for physical therapists using Limber Health
Risk stratification and evaluation of patients' pain and function
Selection of exercises for patients to do at home through a portal
Care navigators reaching out to patients and monitoring their progress
Remote monitoring of exercises and tracking pain and function
Providers are the buyers and pay for the services
Difference between RTM and RPM billing: RTM can be billed by various providers including physical therapists
Potential impact on revenue for physical therapists and improved patient outcomes
Providers, including physicians, PAs, NPs, and physical therapists, can bill RTM codes
Reimbursement for RTM codes varies based on billable milestones achieved
Limber and similar companies support providers with technology and clinical services
RTM codes can be used in fee-for-service and value-based care models
Limber aims to lower total cost of care and improve patient outcomes
Maryland offers innovative value-based care models through programs like Equip
Providers can sign up for Limber's services through a contract and training process
Participating providers may receive shared savings in value-based care models
Patients are informed and consent is obtained for remote therapeutic monitoring
Patient awareness of risk-taking in value-based care models may vary and can be addressed with the state of Maryland
Limber does not have a direct-to-consumer model but works with provider groups in various states
Providers using Limber's system can be identified through partnerships and collaborations
Compliance with therapy can potentially offset or delay the cost of procedures like knee replacements. -
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Discussion topic: Getting paid through the Medicare system
Introduction to CPT codes and HICPICS codes
Medicare's payment process for healthcare providers
Future guests and topics related to Medicare reimbursement
Mention of the Aging Here newsletter and interview opportunities
Differentiating between CPT codes and ICD-10 codes
History and purpose of CPT codes
Explanation of RVUs (Relative Value Units) and how doctors are paid
Simplified process of submitting CPT codes to Medicare for payment
Potential fraud issues in fee-for-service Medicare
Importance of documentation and medical necessity for CPT codes
Challenges with lack of comprehensive guidelines for new codes
Providers struggle with the interpretation and utilization of CPT codes.
Some codes are rarely utilized, while others require expertise to maximize billing.
Coding rules can be complex, with restrictions on code combinations and frequency of billing.
Providers face the risk of financial penalties or legal consequences for incorrect coding.
Medicare is a significant payer and requires compliance with its rules.
Physicians, nurse practitioners, and physician assistants primarily use CPT codes.
Modifiers can be used to bill for additional services or special circumstances.
Hospice CPT codes exist separately from Part B coding.
CPT codes have RVUs (Relative Value Units) that determine payment.
RVUs are divided into work RVUs, which assess the labor involved in a procedure.
Work RVUs consider time, technical skill, physical effort, mental effort, judgment, and stress.
Work RVUs are subject to negotiation and lobbying each year.
The conversion factor translates RVUs into payment amounts.
The conversion factor is subject to annual adjustments and can significantly impact reimbursement. -
Physicians and other senior-serving professionals trying to operate within the complicated Medicare ecosystem must be constantly learning, as the landscape, rules, tools, and vendors are in constant flux.
We interview eldercare and Medicare industry experts, do deep dives into their companies, services, and experiences, and share their stories and insights with you.
- The Mastering Medicare Podcast is back from a long hiatus caused by both hosts taking W2 jobs during the COVID-19 pandemic.
- During their time away, they learned a lot about the changing landscape of Medicare, especially with the rise of AI and value-based care models.
- Value-based care was a particular focus in the discussion, with Dr. Mohseni sharing his experiences working at Optum and learning about the value-based care model, particularly within Medicare Advantage.
- Value-based care is touted as the future care model for the US healthcare system. It aligns incentives for patients, providers, and health plans, reducing waste and delivering more effective care at lower costs.
- The co-hosts contrasted value-based care with the fee-for-service model, pointing out that value-based care requires all parties to be financially invested in patient outcomes, incentivizing efficiency and effectiveness in care.
- They also highlighted the importance of collaboration and communication in value-based care, contrasting it with the disjointed nature of fee-for-service care, where different health providers often work in silos.
- An example of effective communication was shared from Dr. Mohseni’s time at Optum, where real-time notifications were used to coordinate care for patients who arrived at the emergency department, leading to better outcomes for the patients and more efficient care delivery.
- The speaker expresses curiosity about why the value-based healthcare system isn't prevalent, considering its beneficial aspects, such as better access to specialists and greater collaboration between healthcare providers.
- Questions are raised regarding the incentives for primary care doctors to transition from the regular fee-for-service model to a more complex value-based model, with no clear motivation at the moment.
- The discussion mentions gradual efforts by Medicare and CMS (Centers for Medicare and Medicaid Services) to encourage a move towards value-based healthcare, through strategies such as upside gain, share upside models, and ACOs (Accountable Care Organizations).
- The Medicare Advantage (MA) model, which has been fully at risk for some time, is described as an effective example of a value-based system.
- The complexity of intermediary programs in the fee-for-service model is noted, as many providers either can't understand the rules or choose not to participate due to the complexity.
- The speaker then elaborates on the workings of MA plans, wherein health plans are paid by the federal government per member per month to take full global risk on a patient for all of their professional medical expenses.
- These MA plans then delegate this risk to a selected medical group, which then uses the allocated funds to manage the patient's healthcare. The remaining difference between the allocated funds and actual healthcare costs becomes the medical group's profit.
- This model incentivizes medical groups to keep patients healthy and manage their costs efficiently.
- The allocation of funds enables medical groups to acquire services like dieticians or care managers, which are often missing in the traditional fee-for-service model. This allows for a more holistic, patient-centered approach to healthcare.
- The conversation discusses a situation where a patient contacts their doctor's office after hours, and rather than being directed to the emergency room, the doctor is willing to solve the issue over the phone. This is because the doctor is being compensated monthly, rather than by individual visits or treatments.
- It is stated that any company can start a Medicare Advantage (MA) plan and people can sign up for it. However, these companies often contract with groups like Optum to handle the provision of care. This is paid for by a fraction of the funding that Medicare provides to the MA plan.
- Doctors are incentivized to provide extra value in their services and keep costs low because they receive a chunk of money to provide the necessary services, and they keep the difference of what they don't spend.
- In the case of a patient with more serious health conditions, a system of risk adjustment is in place. This means that doctors annually document the patient's conditions, which contributes to their Health Condition Category (HCC) score. The higher the score, the more funding the medical group receives.
- The conversation suggests that the Medicare Advantage world has been increasingly focused on risk adjustment, given its substantial impact on revenue. However, this has raised concerns about gaming the system and potential fraud.
- In the future, it is suggested that there will be a greater focus on better patient outcomes and coordination to maintain profit margins, rather than on risk adjustment. This is expected to spur innovation and the creation of improved solutions for patients.
- The conversation discusses the idea of reducing healthcare utilization with a focus on reducing Emergency Department (ED) visits and hospitalizations.
- The speakers note that much of the current thinking centers on reducing the need for hospital care through better patient services, new tech, and addressing social determinants of health.
- Two additional areas of potential reduction in healthcare spending are identified: pharmacy (particularly unnecessary use of expensive brand name drugs when generics would suffice) and unnecessary surgeries or inefficient surgical procedures.
- The speakers emphasize that a lot of care currently delivered in hospitals could be effectively and more cost-efficiently delivered at home.
- The conversation then transitions to discussing how the home-based care trend can connect with value-based systems and the opportunities for innovation this brings. There's a focus on how different players in the healthcare system (from family caregivers to healthcare professionals to tech innovators) can collaborate to improve patient care.
- They mention the establishment of Medicare Advantage (MA) programs, where healthcare groups receive a capitated payment from Medicare based on a patient's Health Condition Categories (HCC) score.
- The speakers then introduce a new initiative, AgingHere.com, a newsletter focused on facilitating a community around aging in place and home-based care. They invite ideas and stories from their audience to share in this platform. -
Dr. Amy Schiffman and Dr. Alex Mohseni do a deep dive interview with Jonathan Edenbaum, the owner of Eden Homes about the ALF industry.
What is an Assisted Living
What is a Group Home
Small vs large assisted living
Kosher assisted living
Key triggers for transitioning from independent living to assisted living
Standard ratios in assisted living days vs nights
Incontinence as a trigger for assisted living
What patients don't qualify for ALFs
They don't do ALFs, ventilators, certain bed sores (III or IV)
Assessments required for qualifying for ALF
RN needs to reevaluate the resident every 45 days
Some facilities charge more for level of care
Romantic relationships between ALF seniors
State and county unannounced random checks
How to determine a low vs high quality ALF
Do an unannounced visit to check quality
Get family reference
RPM in the ALFs
Zoning requirements for ALFs
HOA issues for ALFs
Risks in an ALF
Marketing ALF services
When an ALF resident gets hospitalized
Eden Homes of Potomac
www.edenhomesofpotomac.com
301-299-0090
Jonathan recommends these finder services:
CarePatrol
FamilyTies
Video version:
https://youtu.be/pJgIa3EWxVA -
In this amazing interview with Robert Bullock, a DC-based Elder Law attorney, from The Elder & Disability Law Center (https://www.edlc.com/), Dr. Amy Schiffman and Dr. Alex Mohseni discuss Medicaid Long Term Care coverage. We cover these topics:
What is Medicaid
Medica long term care eligibility
What does Medicaid waiver mean?
How does one qualify for Medicaid
Medical eligibility for Medicaid long term care
Financial eligibility for Medicaid long term care
Most people are in crisis mode when trying to qualify for Medicaid long term care
How are patients assigned to rehab
Medicaid 5 year lookback
Put your assets into an irrevocable trust at least 5 years before you think you made need Medicaid
Why doesn't Medicaid cover ALF
Medicaid long term care payments are like a loan
Medicaid estate recovery
Atlantic article on Medicaid estate recovery (https://www.theatlantic.com/magazine/archive/2019/10/when-medicaid-takes-everything-you-own/596671/)
Life care Planning and Management
At what age should everybody talk to an elder law attorney
Video version of this episode: https://youtu.be/EIwz0kv_O1o
Robert's contact information: 202-452-0000
https://www.edlc.com/
on AVVO.com (https://www.avvo.com/attorneys/20036-dc-robert-bullock-672970.html)
Thank you to our sponsor:
The RISE Virtual Medicare Marketing & Sales Summit taking February 19, 22-23, 2021, is offering 15% off with promo code POD15 to our listeners. To learn more about this event visit medicaremarketingsalessummit.com (https://www.medicaremarketingsalessummit.com/) #RISEMMS2021 -
Danielle Doberman, MD, MPH, HMDC, is the Clinical Medical Director for Palliative Medicine at Johns Hopkins Hospital. Dr. Amy Schiffman and Dr. Alex Mohseni dive deep into the world of Palliative Care to understand what this commonly misunderstood specialty is all about. We cover the following:
What is palliative care / palliative medicine?
What symptoms does palliative focus on?
How does palliative operate as a team?
Hospital-based vs outpatient palliative care
Palliative care vs hospice
https://www.PrepareForYourCare.org
Who should be a palliative care patient?
Where do most referrals to palliative care come from?
https://getpalliativecare.org
Center to Advance Palliative Care www.capc.org
Interaction and relationship between PCPs and palliative care
Contracting for safety and consent in palliative care
Palliative care pain management
Palliative Sedation (aka Proportional Sedation)
Article: "Best Case Worst Case" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4747100/)
Youtube video "Best Case Worst Case" (https://www.youtube.com/watch?v=FnS3K44sbu0)
Palliative care is not giving up
Palliative care services lose money but they help the hospital because they reduce inpatient length of stay
$3,000 of Part A savings per palliative care patient
Typical patient volumes for palliative care
Youtube version of this interview: https://youtu.be/poYoZ807SWU -
Dr. Amy Schiffman and Dr. Alex Mohseni interview Steve Ackerman, the owner of Spectrum Medical, and do a deep dive into the world of Durable Medical Equipment (DME).
Introduction to Steve Ackerman and Spectrum Medical (https://www.spectrummedical.net/)
What is Durable Medical Equipment DME?
Not disposable, has to be able to sustain repeated use
Can't be used in the absence is disease or injury
Can't be an environment improvement
Can't be a safety item
Controversy with DME beds
Semi-electric bed
Patients who need frequent immediate change in body position
Different types of DME wheelchairs
What is a seating clinic?
What are Assisted Device Professionals
Choices of wheelchairs
K codes for wheelchairs
Hemi wheelchairs
K3 standard wheelchair is the most ordered wheelchair
Parachute ordering portal
Walkers as DME
Medicare local coverage determination (LCD)
Every equipment has its own LCD
Clinical inference
Secondary market for DME
5-year limit
Indoor vs outdoor use of DME
What is a transport wheelchair?
Fraud and abuse in DME
How PT/OT help with getting DME
Hoarders
DME company doesn't remove old equipment
Implications of having and MA plan for DME
Rollators are not covered
Walkers vs Rollators
How quickly can DME be delivered?
Aging in place
Video version: https://youtu.be/m9dM7PT63M0 -
Dr. Amy Schiffman and Dr. Alex Mohseni interview Michael Hughes, principal at Mitchell-Lowey, LLC, and do a deep dive into Medicare Advantage plans, especially as they relate to supplemental benefits like private duty home care services. We discuss:
What is Medicare Advantage
MA plans offer supplemental benefits
CMS is realizing that SDOH determine health and cost outcomes
Who costs the system the most
Examples of supplemental benefits include things like home care and pest control
How many MA plans are there
SSBCI - special supplemental benefits for the chronically ill
How does an MA plan measure effectiveness of supplemental benefits
How do physicians order supplemental benefits for members
VBID model
Conversion rate from MA plan to private pay
What are the downsides of choosing an MA plan
Why MA plans care about the quality of supplemental benefits
MA plans as a percentage of total Medicare population by state (Link (https://www.kff.org/medicare/state-indicator/enrollees-as-a-of-total-medicare-population/?activeTab=map¤tTimeframe=0&selectedDistributions=overall&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D))
Link to Michael Hughes: https://www.linkedin.com/in/michael-hughes-7010221/
Video version: https://www.youtube.com/watch?v=7NrtiqkkHtQ -
In this episode we do a deep dive into Hospice with our guest, Cathy Gurson. She teaches us everything we ever wanted to know about Hospice. Here are some of the topics we cover:
How do people get referred to hospice
Hospice is covered 100% by Medicare part A
What does hospice cover
How to get Part B medical care covered while under hospice
Hospice reimbursement model
Hospice per diem
Three levels of hospice care
Pier diem changes at the higher levels of care
For profit vs non-profit hospice
Hospice certificate of need requirements
What questions you should ask about when interviewing a hospice
CHAP certification for hospice
Transitioning - what does transitioning mean in the context of hospice?
How to know when a hospice patient is dying
Does hospice pay for food and nutrition
Tube feeding hospice patients
Measuring mean arm circumference (MAC) as a measure of nutritional decline
Who is making the hospice recertification?
Hospice patient’s relationships with their their PCP and hospice medical director
DNR status and resuscitating hospice patients
Most common reasons somebody leaves hospice status
What is the role of PCPs for patients in hospice status
What a PCP can bill for care plan oversight for a hospice patient
Retroactive hospice status changes
What happens if you don’t requalify for hospice recertification?
Graduating from hospice
Video version: https://youtu.be/qat1HZicdrA -
Dr. Amy Schiffman and Dr. Alex Mohseni do a deep dive into Alex's frustrations with documentation, billing, coding and his EMR in setting up a solo practice. They discuss the issues that make it nearly impossible for small practices to thrive if they agree to accept health insurance.
Link to Youtube video version: https://youtu.be/kI5QqVA9NAQ -
Dr. Amy Schiffman and Dr. Alex Mohseni talk with the team from Fox Rehab (https://www.foxrehab.org/) about physical therapy, occupational therapy and speech pathology and uncover all the hidden issues, challenges, and secrets of this huge industry. If you are a senior-serving professional or medical provider who orders PT, OT or Speech services for your clients, you need to listen to this episode.
Alex and Amy cover the following topics:
Speech Therapy vs Speech Language Pathologist
In-home PT, OT and speech therapy for geriatric patients
Part A rehab vs Part B rehab
When and why do you flip from Part A therapy/rehab to Part B rehab?
How do you continue to qualify for Part A therapy?
Who decides whether a patient has reached their therapy goal - the ordering provider or therapist?
What does a physical therapist do?
What does an occupational therapist do?
What does a speech therapist do?
PT vs OT vs Speech
Functional independence
Activities of daily living
What does Medicare pay for with Part B PT, OT and Speech Therapy
Two requirements for Medicare to pay for Part B rehab: medical necessity and skilled need
The Therapy Cap for PT and Speech
Part B works on a calendar year basis
How to get an exception to the Therapy Cap for PT, OT and Speech Pathology
Coding and billing PT, OT and SLP encounter CPT codes
What is a low-tech augmentative communication device?
What is the common work file in Medicare rehab?
How often does a physical therapist usually go to a person's home?
What is the patient responsibility or copy for Medicare Part B rehab and physical therapy?
Part B rehab is not home health
Which types of providers refer to Part B rehab the most?
Most common reasons for referral for Part B Rehab all revolve around falls: gait, balance, and weakness
Do not have to be homebound for Part B rehab in the home
Common mistakes when referring to rehab
How to write an order for PT, OT, or speech and what CPT codes to include
Part B rehab does medication reconciliation
How to order DME
What is a 3-in-1 commode
How long does it take to get a hospital bed paid for by Medicare
FoxRehab.org -
With COVID-19 causing lots of seniors to be stuck at home and not be able to access the medical care that they need, Alex decides to start his own medical practice to serve this population. Alex chronicles everything he's doing to start this practice and gets Amy's help in figuring out lots of the details and issues. In this episode Alex and Amy discuss Medicare enrollment for individuals, organizations and employee providers, deploying Athenahealth EMR, and getting the first patients. Alex's Medicare telemedicine practice is called Canary Doctor (https://www.canarydoc.com).
Dr. Alex Mohseni and Dr. Amy Schiffman are two Emergency Medicine doctors who are the hosts of MasteringMedicare.net, a podcast helping unearth the secrets of Medicare for healthcare providers and senior-serving professionals.
Video version of episode: https://youtu.be/MeRWrKF6eno -
Part 2 of our incredible interview with Andy Diamond, the President of Diamond Medical Labs and Mobile Medical Imaging. In this amazing episode, Andy teaches us everything about how mobile medical imaging is done in nursing homes, rehabs, assisted livings and in patients' homes.
In part 2 we discuss:
Brief summary of mobile labs episode
What sort of equipment do mobile medical imaging labs have in their cars?
How do you get mobile imaging equipment up a flight of stairs?
How much does a mobile digital x-ray machine cost?
How quickly can you get imaging done in a patient's home?
The logistics challenges of home-based medical care
Managing dispatchers for home-based services
How is the logistics of labs more complicated than radiology?
Is there a transportation fee for radiology done in the home?
How do trip fees work when visiting an assisted living or nursing home?
How do you split the trip fee?
What technology is used to manage logistics for home-based care?
Lab tests are not subject to Medicare deductible but imaging is
What could providers do better when ordering labs and radiology?
Training nursing home staff on anatomy
Point Click Care
No trip fee on EKG and ultrasound; trip fee only on x-rays
Do lab and radiology providers need to get patient consent when they visit a nursing home or assisted living?
What is the minimum percent of tests a lab must do in-house?
How many patients per day can a mobile radiology tech perform?
How quickly do labs need to be run? -
With COVID-19 causing lots of seniors to be stuck at home and not be able to access the medical care that they need, Alex decides to start his own medical practice to serve this population. Alex chronicles everything he's doing to start this practice and gets Amy's help in figuring out lots of the details and issues. Alex and Amy discuss Medicare enrollment for individuals, organizations and employee providers, choosing an EMR, choosing a telemedicine platform, setting up medical malpractice insurance, planning for NPs and PAs, rules for supervision of NPs and PAs, reimbursement models, and how to figure out how much you are going to get paid.
Dr. Alex Mohseni and Dr. Amy Schiffman are two Emergency Medicine doctors who are the hosts of MasteringMedicare.net, a podcast helping unearth the secrets of Medicare for healthcare providers and senior-serving professionals.
Video version of episode: https://youtu.be/ebZZkHHBy30 -
Amy and Alex interview Andy Diamond, the President of Diamond Medical Labs and Mobile Medical Imaging. In this amazing episode, Andy teaches us everything about how labs are done in nursing homes, rehabs, assisted livings and in patients' homes.
In part 1 we discuss:
How and why do lab companies have contracts with nursing homes and assisted living facilities?
Part A and Part B billing for labs in the same facility
Figuring out Same and Similar in the lab world
Patient financial responsibility for labs drawn in a nursing home
Lack of centralized database of lab data
Integration with state health information exchange / CRISP
What is a health information exchange?
Why does CRISP charge the lab company to participate?
Nursing home is paying for some lab tests directly
Lab billing denials
Revenue cycle management in the lab world
What are the most common mistakes and issues when nursing homes and assisted livings order labs?
What labs aren't allowed to tell ordering physicians?
Alex thinks the rules for ordering labs are stupid
Trends in lab testing
Molecular testing - why is molecular testing becoming more popular?
Who collects urine samples in nursing homes and homebound patients?
What is the cost of molecular testing and is the denial rate different?
What things to consider other than just the cost of a lab test?
Workflow requirements for molecular testing
PGX testing - what is it and why would you order it?
Cost of PGX testing
Are the results from PGX testing easy to interpret?
Effect of PAMA on labs and lookback for lab payments
Why doctors can't have their own labs -
Amy and Alex interview Dr. Howard Haft, the Executive Director of the Maryland Primary Care Program, and Tammy Liu, a Primary Care Transformation Coach. We do a deep dive into the Maryland Primary Care Program and understand how this amazing innovative program is helping physicians provide higher quality more holistic care while providing physicians the tools and resources they need to provide that care in an efficient and low-friction way.
We discuss so many valuable topics in this episode:
Who is Dr. Howard Haft
What is the Maryland Primary Care Program (https://health.maryland.gov/mdpcp/Pages/home.aspx)
Maryland All Payer Model
Global Budget Revenue Hospital Payment Model
What do Primary Care Practice Transformation Coaches do
Advanced Alternative Payment Model
Track 1
Track 2
Upfront payments
Is the Maryland Primary Care Program only for Medicare
Carefirst participation in the Maryland Primary Care Program
How much extra can physicians earn from the Maryland Primary Care Program
Average $40,000 per year per physician
Care Transformation Organizations
Administrative requirements of the Primary Care Program
ECQMs
Alex's mind gets blown
Empathy in healthcare
20% Reduction in avoidable admissions
Predicting high risk patients and avoidable admissions
How Maryland is using machine learning to support primary care doctors
Social Determinants of Health services in Maryland
How to order SDOH services from CRISP
How community-based organizations can work with the Maryland Primary Care Program
211 service in Maryland (https://211md.org/)
Global Budget contracts
Maryland Stakeholder Innovation Group (https://www.mhaonline.org/transforming-health-care/tracking-our-all-payer-experiment/stakeholder-innovation-group) -
Alex and Amy discuss telemedicine and RPM (remote patient monitoring) in the COVID-19 Era. Medicare has published new rules for telemedicine to help cope with the novel coronavirus epidemic. Medicare also published new rules for RPM that went live Jan 1 of 2020. These rules create valuable opportunities for medical providers, especially with COVID-19 quarantine and isolation requirements.
We discuss:
appreciation for our emergency medicine colleagues
original medicare telemedicine telemedicine requirements
Medicare telemedicine geography requirement
Medicare telemedicine originating site requirement
COVID19 Medicare telemedicine reimbursement updates
HHS won't audit preexisting relationship rule, but what about MACs?
Provider licensure requirements for telemedicine
Fee for service telemedicine billing guide (https://www.cchpca.org/sites/default/files/2020-01/Billing%20Guide%20for%20Telehealth%20Encounters_FINAL.pdf)
Home health telemedicine
RPM (Remote Patient Monitoring) COVID19
Connection between real estate tax code and healthcare opportunities
Why is Medicare paying for RPM
How does remote monitoring work
Alex's Concierge Medicine RPM article (https://www.linkedin.com/pulse/medicare-now-pays-concierge-medicine-subscription-fees-alex-mohseni/?trackingId=sIjYed4wsIb9nGMn0rorQg%3D%3D)
How much does RPM pay
Medicare eVisit non-face-to-face encounters
Role of RPM with addressing loneliness in seniors
Some states' Medicaid programs pay for RPM
Kudos to Dr. Blake McKinney from CirrusMD (https://www.cirrusmd.com/)
Telemedicine pictures need to be treated like radiology films
Accuhealth RPM website (https://accuhealth.tech/en/home)
Email us at [email protected] (mailto:[email protected]) or [email protected] (mailto:[email protected]) for our RPM Workbook -
Alex and Amy discuss the urgent need during this COVID-19 pandemic for folks to think about difficult end-of-life deicisions and they walk the audience through the details of filling out the MOLST form.
MOLST: Medical Orders for Life-Sustaining Treatment
POLST: Physician's Orders for Life-Sustaining Treatment
In this episode, we discuss:
What is a MOLST form
What is a POLST form
Why should we talk about end of life care
Coronavirus / COVID-19 concerns
When should you fill out a MOLST form?
Who should fill out a MOLST form?
Can you make copies of a MOLST form?
Where should you keep your MOLST form?
What is CPR?
What is intubation?
MOLST form options -
In this Mastering Medicare episode, Dr. Amy Schiffman and Dr. Alex Mohseni do a moderate dive into Medicare Part D. We discuss the following topics:
What is Part D Medicare
Opt in Part D
Premium calculation for Medicare Part D
What is the Medicare Donut Hole?
Medicare Part D Donut Hole
4 stages of Part D
Part D deductible stage: first $435
Part D initial coverage stage: first $4,020, up to 25% of cost of medication
Tiers of medications in Part D
Part D tier 1 medications
Part D stage 3: donut hole, 25% patient responsibility
Part D stage 4: catastrophic stage, copay
Visit Mastering Medicare at MasteringMedicare.NET (https://www.masteringmedicare.net/) - もっと表示する
