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Physicians Are Leaving Coordinated Care Dollars on the Table


A new Medicaid rule gives physicians the potential to earn new income by providing non-face-to-face chronic-care services. So why are so few physicians participating?

Practice Management, Chronic Care, Endocrinology

There’s gold in them hills. Okay, maybe invoking the infamous cry from the gold rush days is exaggerating things just a bit, but there’s certainly dollars to be had—federal dollars—by physicians for coordinating care for Medicare patients.

And yet, much of it goes unclaimed.

In 2015 the Centers for Medicare and Medicaid Services began paying physicians an average of $42 per-patient per-month for non-face-to-face chronic-care services. The goal is to improve care while reducing hospital readmissions and overall costs. But despite roughly 35 million Medicare beneficiaries being eligible, CMS had received reimbursement requests for only 100,000 beneficiaries by late 2015.

Neil Smiley, CEO and founder of Loopback Analytics, says one of the reasons for the low reimbursement requests is that there’s still a fair amount of education needing to be done. But that’s not all.

“I think physicians are fairly jaded about the amount of time they’re going to have to put into the administrative aspect of this, and whether or not they can make money on a code that only pays $42, given the paperwork and administrative oversight,” Smiley says.

Is It Worthwhile?

Smiley says there’s a huge concern by physicians who have been down this road before that they will make this effort, submit codes that pay only a modest amount, only to have the vast majority of claims be rejected. If they then have to rework the rejected claims, they actually end up losing money on the deal.

“Physicians may just say, ‘Forty-two bucks … how can we possibly make this thing happen?’” Smiley says.

And yet, according to a study published in the Annals of Internal Medicine, “practices could expect approximately $332 per enrolled patient per year” if chronic care management services were delivered by registered nurses. That equates to more than $75,000 of net annual revenue per full-time employed physician.

Smiley agrees that “the lion’s share of the work would have to be supported by care extenders.” That means taking the time to plan strategy on how practices can better leverage extenders regarding these touch points, and capturing the information that comes from those touch points.

“I do think that this can be a moneymaker for physicians,” Smiley acknowledges, “but it’s going to require a little bit of set up to do it at some scale.”

Co-Pay Barrier

The other barrier to adoption, Smiley points out, is that this service requires a 20% co-pay. To the extent that some physicians may already be providing chronic care management, patients have not been paying for it. Now not only do physicians have a new code to report on and how to leverage it through extenders, but they also have to inform their patients of the co-pay.

“Every time the physician bills for $42, the patient is potentially going to see a bill for $8,” Smiley says. “Physicians have to think about how that gets messaged, and how much grumbling could potentially come in. How do you manage that process? It has to be sold to patients as something that’s going to create value for them.”

And that could be a tough sell. Physicians have been trained that anything that happens between office visits is not reimbursable, which means patients have grown accustomed to not paying for anything between office visits.

“They’re going to have to be re-educated on that,” Smiley says.

Talk to Patients

Smiley suggests the first thing physicians should do is a quick screen of the patient panel they serve. For patients to qualify for this reimbursement two or more chronic conditions must be present. Based on the diagnosis codes created in the practice EMR and the number of Medicare patients the practice serves, physicians can get a pretty good snapshot about how many patients would qualify, and if it makes financial sense for the practice.

“The ability of tracking where your patients are, knowing when they’re arriving or leaving particular care settings is one of the critical things you need to have in order to manage this process,” Smiley says.

He also suggests an informal survey of patients, perhaps at the time they’re in the office, to estimate their willingness to participate.

“That cuts right to the fear that many physicians have,” he says. “If I ask my patients to do this, what kind of firestorm am I going to kick up? But it’s also a selling opportunity.”

In other words, position it not as “would you be willing to pay $8 when I don’t see you in the office,” but more as something Medicare is doing to provided added benefit to the patient.

“I think many physicians will be surprised by patients who not only see the need for their doctors to be paid for these services, but would really like to benefit from what this is offering.”

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