License To Steal

Medicare-How The Chronic Care Reimbursement Scheme Is Being Gamed

This post is a follow-up to my most recent prior blog. There I delved into an inquiry driven by a patient reporting they were being “assigned” a primary physician by their new Aetna Medicare PPO insurance underwriter. This past week, another of my established patients brought me a “patient care” letter. This letter was sent from his Florida Blue Medicare insurer. He informed me he has had other communication attempts from his plan including unsolicited nurse health history reviews. Many patient have reported to me in the past 2 years of unsolicited nursing navigator calls.

The Guise Of Being Your Health Care Navigator; An Example Of Mission Creep And An Example Of A Middleman Entry Into Chronic Care

My patient provided me a letter sent to him, along with an enclosed Brush Kit for Fecal Immunochemical Testing. This official looking letter was signed by Dr. Thomas Graf, M.D., FAAFP (Fellow of the American Academy of Family Physicians). He is the Vice President & Chief Medical Office of Florida Blue Medicare.

This letter informed my patient Florida Blue Medicare was teaming up with Quest Diagnostics lab to make it easy to check for colon cancer from “the comfort of your own home”. “At no additional cost to you”. The offer also includes an incentive to “earn $15 in HealthBlue Rewards” upon proof of completing this test. If you have questions you can all their Member Services 1-800 number.

Enclosed with the letter is an official lab requisition (order) form. It is signed by physician, Dr. Lianne Marks NPI # 1114918349. This doctor practices in Colorado based upon my internet search. I have not had the opportunity to confirm she is aware of her credentials being attached to this order. At the bottom of the form is a signature for my patient’s “participation” which if signed, attests that upon receiving the test service, the patient is in agreement with Terms of Service.

This letter folks, is an example of how the Insurance Companies use chronic care incentives to allow them to begin trying to be your healthcare provider. In my book, that is another phrase for practicing medicine.

Terms Of Services-From The Letter

“This is a Quest Diagnostics Employer Population Health program”. This patient is retired and thus not employed. The second paragraph clarifies that the signature indicates the patient is participating freely and voluntarily, assuming any risks associated with the screening process. There is no actual explanation of what those risks may be. Bullet points for the Terms of Services further state:

• Authorization of use of genetic information if obtained.

• Authorization of your test results and any history provided through Quest’s Health Questionnaire may be shared with other third parties authorized by the program. No specifics.

• Signature authorizes Quest Diagnostics EPH to communicate regarding your participation in the program. Communications can include SMS text messages, etc.

• You are agreeing to be responsible for the accuracy of your personal information provided to the company.

• Participation in the program DOES NOT CONSTITUTE THE PRACTICE OF MEDICINE.

• Signature agrees to “hereby release and discharge, to the extent of the law all parties of any liability for any outcome from participating in this program”.

So What Can Go Wrong With Testing My Stool For Occult Blood Doctor?

Based upon this patient’s solicitation, the Mighty Blues has assumed no physician is caring for this patient. Despite their ability to procure records from the patient’s actual providing physician (me), they have not sought such information. Why might that be? Short Answer- they don’t really care. This is a program to get their Camel’s Nose Under The Tent.

Never mind that I routinely monitor my patients for Appropriate Health Screening. This particular patient doesn’t need the unsolicited offered service. Any patient who signs off on such a letter will be providing the insurance company and Quest diagnostics access to their personal health information. The test, if positive, would lead to a recommendation to be referred to a Gastroenterologist for colonoscopy screening. It is rare but there are potentially life-threatening complications from such procedures. This possibility is nowhere mentioned in the “terms of agreement”, yet the patient by participating and signing the fine print, has indemnified all parties for any such outcome. The subtle coercion of “HealthBlue Reward Dollars” is part of the introduction letter.

So Let’s Go Further Down The Rabbit Hole Of Harnessing Medicare “Quality Metrics” Incentives And Proof Of Care Coordination/Management

Why are Medicare Advantage Plans So Popular To The Insurance Industry? The answer is there are loopholes that are allowing institutions including the Insurance Companies themselves, to get paid to get that nose under the tent. United Health is implicated in playing games in the Skilled Nursing Homes to game profits and access health care information from patients.

I have informed readers in the past about United Health (and the others in the BUCA cartel) finally being scrutinized for upcoding practices. The upcoding occurs through various methods. A primary method is to have Insurance-hired nurses solicit patients for their self reported health histories. From that information the insurance company adds past or irrelevant diagnoses to their profile. Under payment rules, they then get blessed with a larger “multiplier” for their Medicare insured population. The letter I started this blog with is another example of soliciting individuals. They are asked to link to a health questionnaire site to provide health information. This is for trolling for dollars.

Who Else Is Getting In On Chronic Care Payola?

From the above informatic, we see pretty much everyone. Recall from my prior post, the intent of chronic care codes was to provide the patients’ primary care physician reimbursement for supervising and taking responsibility for not just sick care but also finally recognizing it would be helpful for patients to be examined periodically to help in disease screening and wellness maintenance. From the above, there are at least 6 other pathways separate from the primary doctor by which Uncle Sam pays out. Hospitals in particular are positioned to game this through monthly intuitional payment schemes. Already expensive (and individual self paid) Assisted Living Facilities and Senior Community neighborhoods are also being leveraged into these schemes. From my experience the patrons are not aware of what is happening. They are being advised to “check in” with the onsite clinic “just in case” they need urgent attention. Seems benign enough. But the plot thickens.

Let me paint us a picture: What is happening here in Lee County Florida is going on all over the country. Lee Health has its own insurance product, presently mostly linked to Medicaid but also via their Accountable Care Organization product, they are tapping into Medicare payment as well. One thing hospitals are expert at, it is trolling for government dollars. Hospitals whine about how Uncle Sam underpays for their “community dedication” yet they sure are adding more and more government business. The instrument for Lee Health is their Best Care Collaborative and Lee HealthCare Partners companies:

• Best Care Collaborative (BCC): BCC is a wholly-owned subsidiary of Lee Health and functions as an ACO (Accountable Care Organization). It participates in the Medicare Shared Savings Program (MSSP), aiming to improve care coordination and reduce healthcare costs for Medicare beneficiaries. Lee Health

• Lee Healthcare Partners: While Lee Health does not function as a traditional insurance company, it offers insurance-related services through Lee Healthcare Partners. This entity collaborates with various insurance plans to provide coordinated care solutions. leehealthcarepartners.com

And it goes much deeper:

• Lee Health has established collaborations with several senior living communities in Lee County, Florida, to enhance care coordination and provide integrated healthcare services for residents.

• Lee Health has partnered with Cypress Living, the parent organization of Cypress Cove, to provide strategic support for Lee Health’s Home Health agency. This collaboration focuses on workforce development, revenue cycle management, operational efficiency, business development, and clinical programming. Cypress Living+2Lee Health+2Cypress Living+2Cypress Living+1Lee Heal

• While specific details are limited, Shell Point Retirement Community is known to have a relationship with Lee Health, facilitating access to healthcare services for its residents.

• Gulf Harbour Yacht & Country Club opened its 24,000-square-foot HarbourView Center for Sports & Wellness in August 2018. At that time, they were in negotiations with Lee Health to provide onsite physical therapy services. This deal is done. I doubt patients from that neighborhood are aware of the higher hospital charges submitted for their convenient location therapy.

Summary Assessment: What started as a program to help primary care physicians stay in business caring for Medicare patients has been usurped by institutional infrastructure. Under this guise, the hospital systems have found Skilled Nursing Facilities and Senior Living communities to leverage their “hospital locations”, chronic care payment scheme and employed army of providers right into seniors homes. From cradle to grave indeed.

Further, the BUCA health insurance cartel has wedged themselves into the quality care incentive matrix and without any consent, are assigning out of state doctors and nurses working from home to force themselves into Medicare recipients’ living rooms to assure higher payment from “other peoples” money, AKA Medicare and Medicaid.