Mastering Medicare Mastering Medicare

Unconventional episode format: The hosts, Alex and the other speaker, interview each other.
"Networking is Dead": The focus is on the importance of building meaningful relationships rather than traditional networking, especially in the senior and aging space.
Challenges in the Senior Care Industry: Discusses the difficulties in breaking into the senior care market and the importance of building a Rolodex of contacts.
Community Building: Introduces the concept of a Slack group aimed at connecting professionals in the senior care industry.
Value Proposition: Emphasizes the importance of providing value to others in your network.
Security Concerns: Briefly touches on the importance of data security, especially in healthcare.
Accelerating Business Growth: The hosts express their desire to help listeners grow their businesses in the aging space, inviting feedback and participation.

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

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 peo

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