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

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" Youtube video "Best Case Worst Case" 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 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) 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