PART 1 IN OUR SERIES ON STRATEGIES FOR MEDICARE ADVANTAGE PLANS
Medicare Advantage Organizations are challenged to attract and retain physicians in states like California, Colorado, New Mexico, and Florida which are falling behind in meeting patient needs for primary care due to physician shortages. In fact, the lack of physicians required to meet minimum patient needs is expected to continue well beyond 2030.
How do Medicare Advantage (MA) Organizations overcome this challenge? The Centers for Medicare and Medicaid Services (CMS) is offering a collaborative opportunity for Medicare Advantage plans to test ways to improve access and care in MA plans.
Applications must be submitted to CMS by April 16, 2021 for plan year 2022.
The following are five models that CMS will be testing in 2022:
1. Wellness and healthcare planning services
2. Flexible benefits for:
Chronic conditions
Socioeconomic issues
Chronically ill patients (can include using new or existing technologies and/or FDA approved medical devices)
High-value providers
Care management programs
Disease management programs
Reductions in cost sharing for Part C benefits and/or
Reductions in cost sharing for Part D covered drugs
3. Flexible Benefits Rebates (up to $600 per member)
4. Rewards and Incentives Programs for Part C and/or Part D covered benefits (also up to $600 per member)
Medicare Advantage plans can also apply - using a separate application to CMS -to test:
5. Medicare Hospice Benefits
The CMS definition of High-Value Providers includes licensed non-physician health professionals who are qualified to manage patient care without physician oversight. MA plans wishing to innovate should consider collaborating with CMS under its Value-Based Insurance Design Models for Calendar Year 2022 and take advantage of the waivers and financial incentives CMS is offering MA members. Proposing innovative ways to access, manage and measure outcomes from non-physicians to address the physician shortage is likely to be of interest to CMS due to their acute awareness of this issue.
The challenges in using non-physician providers to manage new benefits include 1) contracting for fixed fees, 2) coding care, 3) filing claims, 4) automating reimbursement and 5) complying with 50 different state scope-of-practice rules that govern non-physician care.
By overcoming these challenges, Medicare Advantage Organizations can fill critical gaps in care and test the benefits of doing so with CMS’s blessing.
ABC Coding Solutions is uniquely qualified to help MA Organizations apply to CMS in using High Value Providers to address physician shortages. We specialize in contracting, claims and reimbursement for 2+ million non-physician health professionals. Our solutions overcome technical and business barriers for direct patient access to licensed non-physicians and our patented methods and copyrighted coding system has been successfully field-tested in over 2 million claims.
To learn more about how we can help your organization access more care at less cost while reducing your liability, visit us at www.abccodes.com
About the Author
Melinna Giannini has successfully worked with insurers to help establish reimbursement for integrative healthcare since 1999. As CEO of ABC Coding Solutions, she developed systems and methods to overcome barriers to reimbursement and also led in the development of an integrative healthcare coding system. Her experience includes healthcare legislation, medical billing, claims processing, legal variations in state scope of practice regulations and the impact of coding on U.S. healthcare policy and costs. She has testified before federal agencies, had multiple articles written about her work, been invited to speak to the National Press Club, helped develop comparative outcome studies and has long-standing relationships with integrative healthcare leaders and subject-matter experts. Before her career in integrative healthcare, Melinna designed, sold and monitored self-funded plan benefits for large employers.