Mastering Medicare

E26: Deep dive into DeepScribe with Dr. Dean Dalili. Introduction: Amy and Alex introduce the episode on AI in healthcare, featuring Dr. Dean Dalili from DeepScribe, an AI-based medical documentation service. Dean's Background: Dr. Dean Dalili shares his journey from internist at Johns Hopkins to Chief Medical Officer at DeepScribe, with a career in hospitalist practice, digital health, and leadership roles. Medical Scribes and Documentation: Discussion on the role of medical scribes, both in-person and AI-based, in reducing physician burnout and streamlining patient care documentation. DeepScribe Overview: DeepScribe uses AI to record and transcribe patient interactions, converting them into medical documentation, saving time, and improving patient engagement. Impact of AI on Healthcare: AI captures more detailed patient information, leading to improved patient outcomes. Physicians can review, edit, and sign off on AI-generated notes. Ambient Intelligence: DeepScribe aims to provide not just transcription but also data-driven insights and decision support for providers. AI’s Potential: Discussion on AI assisting clinicians, not replacing them, by handling documentation and improving diagnostic accuracy. Patient Interaction: AI helps providers maintain eye contact and focus on the patient, improving patient satisfaction and engagement. AI Challenges and Future: Discussion on the evolving role of AI in healthcare, with possibilities for AI taking on more decision-making roles while working alongside physicians. Conclusion: The hosts reflect on the potential of AI to change healthcare workflows, and Dean invites listeners to learn more about DeepScribe and its applications in various healthcare settings.

E25: Deep dive into the PACE program with Dr Rob Schreiber and Eric Patzelt from myPlace Health. PACE Overview: Program of All-Inclusive Care for the Elderly provides comprehensive care for seniors, allowing them to live in the community rather than nursing homes. Eligibility: Seniors must be 55+, certifiable for nursing home care, and safe in the community with PACE services. Funding: PACE is funded by Medicare, Medicaid, and individual contributions, with high startup costs and a long-term recovery period. Revenue: PACE receives ~$9,500–11,000 PMPM for dual-eligible members and ~$7,000–8,000 for Medicaid-only members, higher than Medicare Advantage. Services Provided: Includes adult day care, primary care, home care, dental, therapy, nutrition, social work, and transportation. Target Demographic: Serves high-need populations with complex health issues and short life expectancy, helping to manage costs and reduce hospitalizations. Coverage: PACE covers all care aspects except direct housing costs unless in a nursing home, where it covers the non-Social Security portion. Handling Health Declines: Provides immediate care and support, including home visits and temporary nursing home placements. Technology Integration: Uses technology for communication, remote monitoring, and data analysis, especially accelerated by COVID-19. Financial Implications: PACE can save money in the long run by reducing hospitalizations and emergency visits, though initial costs are high. Enrollment: Participants can leave voluntarily or be involuntarily disenrolled due to death, loss of coverage, or moving out of the service area. Comparison to Medicare Models: PACE offers an integrated care model distinct from Medicare Parts A, B, C, and D, operating on a capitated model. Hospice Care: PACE provides comprehensive end-of-life care, but participants must disenroll from PACE to fully access hospice services. Social Work Role: Social workers in PACE advocate for participants, addressing needs and enhancing care through personal connections. Healthcare Innovation: Models like PACE demonstrate potential for improved care and outcomes, with ongoing support and adaptation crucial for success.

Matt Gibson from 90 Days From Retirement discusses the prevalence of unsolicited calls and mail targeting those turning 65 for Medicare plans. He explains the differences between Medicare supplement plans and Medicare Advantage plans, highlighting how brokers navigate the industry to assist clients effectively.

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.

Alex Mohseni, Medicare expert, discusses value-based care in Medicare Advantage, highlighting incentives for efficiency and patient outcomes. Contrasting fee-for-service, they emphasize collaboration and communication in improving healthcare. The podcast explores transitioning to value-based models, reducing hospitalizations, and maximizing outcomes through proper documentation and care efficiency.

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