Mastering Medicare: Recent Episodes
Mastering Medicare
What's the difference between Home Health and Home Care? How do Medicare Part A and Part B work? How do you order DME for your patient? When and how should you order home oxygen? What's new in the eldercare space? For physicians, other healthcare professionals, and senior-serving professionals, interacting with Medicare can be complicated and wrought with pitfalls, which, if not understood and managed, will mire your practice in endless paperwork and frustration. We interview industry experts in every aspect of healthcare, from insurance companies, DME companies, home health agencies, medical providers, and many others, to bring you their real world expertise in the American healthcare system. Your hosts are Dr. Amy Schiffman and Dr. Alex Mohseni, two Emergency Medicine physicians who have branched off from traditional Emergency Medicine to explore and build solutions with a particular focus on eldercare and population health. Join our Facebook group: https://www.facebook.com/groups/602747270479020/ Join our Subscriber List and get exclusive access to our Mastering Medicare Cheat Sheet and other goodies: https://www.masteringmedicare.net/subscribe
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 (https://www.edlc.com/), 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 (https://www.theatlantic.com/magazine/archive/2019/10/when-medicaid-takes-everything-you-own/596671/) 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 (https://www.avvo.com/attorneys/20036-dc-robert-bullock-672970.html) 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 (https://www.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" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4747100/) Youtube video "Best Case Worst Case" (https://www.youtube.com/watch?v=FnS3K44sbu0) 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 (https://www.spectrummedical.net/) 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 (https://www.kff.org/medicare/state-indicator/enrollees-as-a-of-total-medicare-population/?activeTab=map¤tTimeframe=0&selectedDistributions=overall&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D)) 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
Dr. Amy Schiffman and Dr. Alex Mohseni do a deep dive into Alex's frustrations with documentation, billing, coding and his EMR in setting up a solo practice. They discuss the issues that make it nearly impossible for small practices to thrive if they agree to accept health insurance. Link to Youtube video version: https://youtu.be/kI5QqVA9NAQ
Dr. Amy Schiffman and Dr. Alex Mohseni talk with the team from Fox Rehab (https://www.foxrehab.org/) about physical therapy, occupational therapy and speech pathology and uncover all the hidden issues, challenges, and secrets of this huge industry. If you are a senior-serving professional or medical provider who orders PT, OT or Speech services for your clients, you need to listen to this episode. Alex and Amy cover the following topics: Speech Therapy vs Speech Language Pathologist In-home PT, OT and speech therapy for geriatric patients Part A rehab vs Part B rehab When and why do you flip from Part A therapy/rehab to Part B rehab? How do you continue to qualify for Part A therapy? Who decides whether a patient has reached their therapy goal - the ordering provider or therapist? What does a physical therapist do? What does an occupational therapist do? What does a speech therapist do? PT vs OT vs Speech Functional independence Activities of daily living What does Medicare pay for with Part B PT, OT and Speech Therapy Two requirements for Medicare to pay for Part B rehab: medical necessity and skilled need The Therapy Cap for PT and Speech Part B works on a calendar year basis How to get an exception to the Therapy Cap for PT, OT and Speech Pathology Coding and billing PT, OT and SLP encounter CPT codes What is a low-tech augmentative communication device? What is the common work file in Medicare rehab? How often does a physical therapist usually go to a person's home? What is the patient responsibility or copy for Medicare Part B rehab and physical therapy? Part B rehab is not home health Which types of providers refer to Part B rehab the most? Most common reasons for referral for Part B Rehab all revolve around falls: gait, balance, and weakness Do not have to be homebound for Part B rehab in the home Common mistakes when referring to rehab How to write an order for PT, OT, or speech and what CPT codes to include Part B rehab does medication reconciliation How to order DME What is a 3-in-1 commode How long does it take to get a hospital bed paid for by Medicare FoxRehab.org
With COVID-19 causing lots of seniors to be stuck at home and not be able to access the medical care that they need, Alex decides to start his own medical practice to serve this population. Alex chronicles everything he's doing to start this practice and gets Amy's help in figuring out lots of the details and issues. In this episode Alex and Amy discuss Medicare enrollment for individuals, organizations and employee providers, deploying Athenahealth EMR, and getting the first patients. Alex's Medicare telemedicine practice is called Canary Doctor (https://www.canarydoc.com). Dr. Alex Mohseni and Dr. Amy Schiffman are two Emergency Medicine doctors who are the hosts of MasteringMedicare.net, a podcast helping unearth the secrets of Medicare for healthcare providers and senior-serving professionals. Video version of episode: https://youtu.be/MeRWrKF6eno
Part 2 of our incredible interview with Andy Diamond, the President of Diamond Medical Labs and Mobile Medical Imaging. In this amazing episode, Andy teaches us everything about how mobile medical imaging is done in nursing homes, rehabs, assisted livings and in patients' homes. In part 2 we discuss: Brief summary of mobile labs episode What sort of equipment do mobile medical imaging labs have in their cars? How do you get mobile imaging equipment up a flight of stairs? How much does a mobile digital x-ray machine cost? How quickly can you get imaging done in a patient's home? The logistics challenges of home-based medical care Managing dispatchers for home-based services How is the logistics of labs more complicated than radiology? Is there a transportation fee for radiology done in the home? How do trip fees work when visiting an assisted living or nursing home? How do you split the trip fee? What technology is used to manage logistics for home-based care? Lab tests are not subject to Medicare deductible but imaging is What could providers do better when ordering labs and radiology? Training nursing home staff on anatomy Point Click Care No trip fee on EKG and ultrasound; trip fee only on x-rays Do lab and radiology providers need to get patient consent when they visit a nursing home or assisted living? What is the minimum percent of tests a lab must do in-house? How many patients per day can a mobile radiology tech perform? How quickly do labs need to be run?
With COVID-19 causing lots of seniors to be stuck at home and not be able to access the medical care that they need, Alex decides to start his own medical practice to serve this population. Alex chronicles everything he's doing to start this practice and gets Amy's help in figuring out lots of the details and issues. Alex and Amy discuss Medicare enrollment for individuals, organizations and employee providers, choosing an EMR, choosing a telemedicine platform, setting up medical malpractice insurance, planning for NPs and PAs, rules for supervision of NPs and PAs, reimbursement models, and how to figure out how much you are going to get paid. Dr. Alex Mohseni and Dr. Amy Schiffman are two Emergency Medicine doctors who are the hosts of MasteringMedicare.net, a podcast helping unearth the secrets of Medicare for healthcare providers and senior-serving professionals. Video version of episode: https://youtu.be/ebZZkHHBy30
Amy and Alex interview Andy Diamond, the President of Diamond Medical Labs and Mobile Medical Imaging. In this amazing episode, Andy teaches us everything about how labs are done in nursing homes, rehabs, assisted livings and in patients' homes. In part 1 we discuss: How and why do lab companies have contracts with nursing homes and assisted living facilities? Part A and Part B billing for labs in the same facility Figuring out Same and Similar in the lab world Patient financial responsibility for labs drawn in a nursing home Lack of centralized database of lab data Integration with state health information exchange / CRISP What is a health information exchange? Why does CRISP charge the lab company to participate? Nursing home is paying for some lab tests directly Lab billing denials Revenue cycle management in the lab world What are the most common mistakes and issues when nursing homes and assisted livings order labs? What labs aren't allowed to tell ordering physicians? Alex thinks the rules for ordering labs are stupid Trends in lab testing Molecular testing - why is molecular testing becoming more popular? Who collects urine samples in nursing homes and homebound patients? What is the cost of molecular testing and is the denial rate different? What things to consider other than just the cost of a lab test? Workflow requirements for molecular testing PGX testing - what is it and why would you order it? Cost of PGX testing Are the results from PGX testing easy to interpret? Effect of PAMA on labs and lookback for lab payments Why doctors can't have their own labs
Amy and Alex interview Dr. Howard Haft, the Executive Director of the Maryland Primary Care Program, and Tammy Liu, a Primary Care Transformation Coach. We do a deep dive into the Maryland Primary Care Program and understand how this amazing innovative program is helping physicians provide higher quality more holistic care while providing physicians the tools and resources they need to provide that care in an efficient and low-friction way. We discuss so many valuable topics in this episode: Who is Dr. Howard Haft What is the Maryland Primary Care Program (https://health.maryland.gov/mdpcp/Pages/home.aspx) Maryland All Payer Model Global Budget Revenue Hospital Payment Model What do Primary Care Practice Transformation Coaches do Advanced Alternative Payment Model Track 1 Track 2 Upfront payments Is the Maryland Primary Care Program only for Medicare Carefirst participation in the Maryland Primary Care Program How much extra can physicians earn from the Maryland Primary Care Program Average $40,000 per year per physician Care Transformation Organizations Administrative requirements of the Primary Care Program ECQMs Alex's mind gets blown Empathy in healthcare 20% Reduction in avoidable admissions Predicting high risk patients and avoidable admissions How Maryland is using machine learning to support primary care doctors Social Determinants of Health services in Maryland How to order SDOH services from CRISP How community-based organizations can work with the Maryland Primary Care Program 211 service in Maryland (https://211md.org/) Global Budget contracts Maryland Stakeholder Innovation Group (https://www.mhaonline.org/transforming-health-care/tracking-our-all-payer-experiment/stakeholder-innovation-group)
Alex and Amy discuss telemedicine and RPM (remote patient monitoring) in the COVID-19 Era. Medicare has published new rules for telemedicine to help cope with the novel coronavirus epidemic. Medicare also published new rules for RPM that went live Jan 1 of 2020. These rules create valuable opportunities for medical providers, especially with COVID-19 quarantine and isolation requirements. We discuss: appreciation for our emergency medicine colleagues original medicare telemedicine telemedicine requirements Medicare telemedicine geography requirement Medicare telemedicine originating site requirement COVID19 Medicare telemedicine reimbursement updates HHS won't audit preexisting relationship rule, but what about MACs? Provider licensure requirements for telemedicine Fee for service telemedicine billing guide (https://www.cchpca.org/sites/default/files/2020-01/Billing%20Guide%20for%20Telehealth%20Encounters_FINAL.pdf) Home health telemedicine RPM (Remote Patient Monitoring) COVID19 Connection between real estate tax code and healthcare opportunities Why is Medicare paying for RPM How does remote monitoring work Alex's Concierge Medicine RPM article (https://www.linkedin.com/pulse/medicare-now-pays-concierge-medicine-subscription-fees-alex-mohseni/?trackingId=sIjYed4wsIb9nGMn0rorQg%3D%3D) How much does RPM pay Medicare eVisit non-face-to-face encounters Role of RPM with addressing loneliness in seniors Some states' Medicaid programs pay for RPM Kudos to Dr. Blake McKinney from CirrusMD (https://www.cirrusmd.com/) Telemedicine pictures need to be treated like radiology films Accuhealth RPM website (https://accuhealth.tech/en/home) Email us at amy@masteringmedicare.net (mailto:amy@masteringmedicare.net) or alex@masteringmedicare.net (mailto:alex@masteringmedicare.net) for our RPM Workbook
Alex and Amy discuss the urgent need during this COVID-19 pandemic for folks to think about difficult end-of-life deicisions and they walk the audience through the details of filling out the MOLST form. MOLST: Medical Orders for Life-Sustaining Treatment POLST: Physician's Orders for Life-Sustaining Treatment In this episode, we discuss: What is a MOLST form What is a POLST form Why should we talk about end of life care Coronavirus / COVID-19 concerns When should you fill out a MOLST form? Who should fill out a MOLST form? Can you make copies of a MOLST form? Where should you keep your MOLST form? What is CPR? What is intubation? MOLST form options
In this Mastering Medicare episode, Dr. Amy Schiffman and Dr. Alex Mohseni do a moderate dive into Medicare Part D. We discuss the following topics: What is Part D Medicare Opt in Part D Premium calculation for Medicare Part D What is the Medicare Donut Hole? Medicare Part D Donut Hole 4 stages of Part D Part D deductible stage: first $435 Part D initial coverage stage: first $4,020, up to 25% of cost of medication Tiers of medications in Part D Part D tier 1 medications Part D stage 3: donut hole, 25% patient responsibility Part D stage 4: catastrophic stage, copay Visit Mastering Medicare at MasteringMedicare.NET (https://www.masteringmedicare.net/)
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. Here are some of the topics that we cover: What is Medicare Part B What services are included in Part B Professional services Part B Physical Therapy Part B Outpatient Labs Part B Outpatient Radiology Does Medicare pay for DME When does Medicare pay for 911 Medicare Part B is opt in How much does Medicare Part B cost Medicare Part B monthly premium Medicare covers part only 80% Medicare secondary insurance / Medigap / supplemental Part A vs Part B Physical Therapy Cost sharing for radiology Cost sharing for lab tests under Medicare Medicare limits on lab tests DME How do you order DME, wheelchair, hospital bed in a patient's home 13 month lease to own DME Same and similar DME Parachute same and similar DME
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. In this Mastering Medicare episode, we cover: How you qualify for Medicare Qualifying for Medicare via ALS Qualifying for Medicare via ESRD on dialysis Qualifying for Medicare via SSDI disability Medicare and VA insurance History of Medicare Inpatient hospitalization Rehab aka SNF aka nursing home Home health Hospice Medicare copays and cost sharing for hospitalization Medicare part A annual deductible Medicare cost sharing with rehab SNF Medicare part A home health What is Home health? Home health 485 form What is skilled nursing? What does part A PT/OT do? Copay for part A PT OT Home health "taxing effort" Certification of being homebound home health Certification periods for home health Recertification of medicare part A home health Home health aides Home health 45 minutes twice per week Will Medicare pay for wound care supplies? Medicare hospice What is hospice Will Medicare pay for hospice Qualifying for hospice Hospice certification periods What does hospice cover and pay for Hospice payment model Who pays for a hospice patient if they go to the ER? Hospice is a risk bearing entity Hospice certification and recertification periods What does it mean to be admitted to a hospital
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. Brought to you by two passionate but critical physicians who broke away from the conventional career paths of their specialty. In this episode we cover: Dr. Amy Schiffman and Dr. Alex Mohseni introduce themselves Medicare overview Part A overview, including cost sharing Part A: Hospital, Rehab, Home Health, Hospice Part B overview Part B 80/20 split, Medigap / supplemental Part D Inpatient vs outpatient medications Inpatient vs outpatient status Observation status Part C - Medicare Advantage Join our Subscriber List to get your copy of our Medicare Cheat Sheet https://www.masteringmedicare.net/subscribe