Episode 27: CMS CMMI ACCESS Program Introduction by ClinX Academy

In this episode, Amy Schiffman and Alex Moseni dig into the real challenges physicians and innovators face when working inside Medicare. They explore why CMS guidance is often incomplete, how this drives confusion and legal costs, and what it means for startups trying to build sustainable care models. Topics Covered • The Medicare information gap and why CMS publishes only partial guidance • How unclear rules increase legal expense and slow down innovation • Fragmented CMS communication and the absence of a unified how to guide • The complexity of care management codes and EMRs that cannot keep up • Why many clinicians rely on third party spreadsheets for compliance • Hidden payer controls such as Medical Unlikely Edits and their impact on reimbursement • Why physicians must understand financial tools to succeed as leaders • How to segment the 65 plus population for better patient acquisition • Resources for physician executives including the ClinX Academy program • Amy Schiffman’s work with Inter Mezzo Health and Coordology • How ambiguity from CMS affects planning, proformas, and capital raising • Persistent hurdles for startups including credentialing and physician activation

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.

E26: Deep dive into DeepScribe with Dr. Dean Dalili. Introduction: Amy and Alex introduce the episode on AI in healthcare, featuring Dr. Dean Dalili from DeepScribe, an AI-based medical documentation service. Dean's Background: Dr. Dean Dalili shares his journey from internist at Johns Hopkins to Chief Medical Officer at DeepScribe, with a career in hospitalist practice, digital health, and leadership roles. Medical Scribes and Documentation: Discussion on the role of medical scribes, both in-person and AI-based, in reducing physician burnout and streamlining patient care documentation. DeepScribe Overview: DeepScribe uses AI to record and transcribe patient interactions, converting them into medical documentation, saving time, and improving patient engagement. Impact of AI on Healthcare: AI captures more detailed patient information, leading to improved patient outcomes. Physicians can review, edit, and sign off on AI-generated notes. Ambient Intelligence: DeepScribe aims to provide not just transcription but also data-driven insights and decision support for providers. AI’s Potential: Discussion on AI assisting clinicians, not replacing them, by handling documentation and improving diagnostic accuracy. Patient Interaction: AI helps providers maintain eye contact and focus on the patient, improving patient satisfaction and engagement. AI Challenges and Future: Discussion on the evolving role of AI in healthcare, with possibilities for AI taking on more decision-making roles while working alongside physicians. Conclusion: The hosts reflect on the potential of AI to change healthcare workflows, and Dean invites listeners to learn more about DeepScribe and its applications in various healthcare settings.

E25: Deep dive into the PACE program with Dr Rob Schreiber and Eric Patzelt from myPlace Health. PACE Overview: Program of All-Inclusive Care for the Elderly provides comprehensive care for seniors, allowing them to live in the community rather than nursing homes. Eligibility: Seniors must be 55+, certifiable for nursing home care, and safe in the community with PACE services. Funding: PACE is funded by Medicare, Medicaid, and individual contributions, with high startup costs and a long-term recovery period. Revenue: PACE receives ~$9,500–11,000 PMPM for dual-eligible members and ~$7,000–8,000 for Medicaid-only members, higher than Medicare Advantage. Services Provided: Includes adult day care, primary care, home care, dental, therapy, nutrition, social work, and transportation. Target Demographic: Serves high-need populations with complex health issues and short life expectancy, helping to manage costs and reduce hospitalizations. Coverage: PACE covers all care aspects except direct housing costs unless in a nursing home, where it covers the non-Social Security portion. Handling Health Declines: Provides immediate care and support, including home visits and temporary nursing home placements. Technology Integration: Uses technology for communication, remote monitoring, and data analysis, especially accelerated by COVID-19. Financial Implications: PACE can save money in the long run by reducing hospitalizations and emergency visits, though initial costs are high. Enrollment: Participants can leave voluntarily or be involuntarily disenrolled due to death, loss of coverage, or moving out of the service area. Comparison to Medicare Models: PACE offers an integrated care model distinct from Medicare Parts A, B, C, and D, operating on a capitated model. Hospice Care: PACE provides comprehensive end-of-life care, but participants must disenroll from PACE to fully access hospice services. Social Work Role: Social workers in PACE advocate for participants, addressing needs and enhancing care through personal connections. Healthcare Innovation: Models like PACE demonstrate potential for improved care and outcomes, with ongoing support and adaptation crucial for success.

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 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.

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, 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 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 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 #RISEMMS2021