Who’s Poaching Your Patients?


Understanding the answers to three simple questions can stop the poaching of your patient’s and generate a substantial amount of additional revenue for your practice.

On the heels of the sweeping Healthcare reform changes, a national group of business and healthcare professionals came together to establish solutions to the dilemmas facing physicians. Their primary mission was to develop a methodology for physicians who presently are overextended in today’s environment with shrinking reimbursements and additional requirements while reducing disruption or burden to the physicians.

After engaging for an extended period of time with various physician groups, a shocking realization began to emerge with three simple questions with one powerful and practical solution. The first question posed was “Given today’s requirements for thorough patient documentation on HEDIS measures, Risk Adjustment Factors (RAF) and Hierarchical Condition Categories (HCC), Why are physicians not performing and documenting detailed Annual Wellness Visits (AWVs)? The answers was immediately self-evident with little research required. Simply stated, physicians at present already spend an inordinate amount of time per week on administrative paperwork as it is. Why then would they choose to spend an additional 45 to 60 minutes of their time to fill out a five to nine page form per patient for a billing event that is less than 1/3 of what their time is worth? A physician literally needs to force themselves to find the time to accomplish what is largely tantamount to fulfilling an administrative task while foregoing their primary responsibility of caring for those patients that actually present themselves for care and treatment.

The second question became as self-evident as the first. Would a physician be willing to allow a third party to examine their patient’s? As little surprise, the majority of physicians initially responded to the negative. “If I worked so hard to build my practice and my relationship with my patients, why then would I risk allowing a third party to potentially poach my patients from under my nose?”

Imagine their surprise when I showed them that was exactly what was happening and they were not receiving any benefits.

The reality of the situation is simple. Medicare Advantage Carriers (MAPs) receive increased reimbursements from Medicare based on properly documented HCC codes to their member base and ACOs require RAF and HCC coding on their member base to preserve their Benchmarks. Both MAPs and ACOs need to capture this information on every member, every single year. Most MAPS and ACOs require over 200 HEDIS measures on each member and mandate that it be performed by a Physician or Nurse practitioner. To complicate matters, most MAPs have individual forms and requirements for the AWVs resulting in confusion for the physicians attempting to perform them with the end result of having over 19% of first time billing submissions being rejected as incomplete or for errors. For these reasons and because the reimbursement to the physician is relatively low, the national average for physicians performing the complete AWV to the carrier’s standards is less than 20%.

Because of the low amount of physicians completing the AWVs, a small percentage of MAPs have been hiring third party providers to complete them directly on their members. Some carriers are even forcing physicians to allow these third party providers into their practice to perform these examinations. To make matters worse some of these third party providers were actually enrolling the patients they were servicing in their own practice’s as well as patient management and disease management programs in direct conflict with the physicians of record. Simply stated, their patients were being poached, one by one.

What then might be the solution?

Armed with the understanding of the situation and with the full participation and support of the physicians, we were able to work together to enact and implement critical changes with surprising and unexpected positive results. We created a third party medical practice with a special program for the sole purpose of performing Annual Wellness Visits on behalf of the physician. This was accomplished by performing the AWVs in the patient’s home such that there was absolutely no disruption to the physician’s office staff, scheduling or space. The results of these examinations on each patient were sent directly to the physician, as well as to the insurance carrier.

The new program was by design purposefully created so as to be perceived by the patient as a direct extension of the physician’s office. Physicians as a result were able to spend their time performing medical services on their patients, instead of on administrative functions while increasing their revenues at the same time. Because the program works in collaboration with the physician, for which they were now receiving additional clinical information and HEDIS measures on their patients, they reported that as a result they were able to provide a higher quality of care to their patients. Relationships between physician and patient were also strengthened which resulted in improved patient compliance and outcomes.

Physicians further reported that by collaborating with our third party program a majority of their patients were now receiving their AWVs, As a result they received several additional distinct advantages. Physicians began realizing that these in-home visits created referrals back to their office and became a means of avoiding costly crisis-care interventions in the ER or hospital setting, and had the net effect of increasing their office visits and subsequent reimbursements.

Additionally, during the Medicare Advantage open enrollment period, many physicians reported receiving a larger amount of patients from the carriers as a result of having the AWVs performed on their patient’s. Furthermore, many inactive patients were reactivated and physicians also began to realize that certain information and documentation that was collected while in the patients home was otherwise impossible to accurately facilitate, such as, medicine reconciliations, environmental observations, dietary assessments, all resulting in a decrease in unnecessary or avoidable crisis care interventions while increasing overall patient compliance.

The end result for physicians is greater contact with their patients through our third party intervention with less nuisance office visits, while at the same time realizing increased practice revenues.

The moral of the story is a simple one. Even though a thorough AWV is a service that most physician’s find difficult to provide, or simply a nuisance, you may benefit significantly in a number of ways by collaborating directly with a third party to provide this service to your patients on your behalf, and serves to reinforce and strengthen your relationship with them as well as their insurance carriers.

Damon R. Kenton, PhD.
Chairman/CEO Novus Healthcare

After serving in the United States military and attending the University of Minnesota, Dr. Kenton started his career in 1993 in the investment-banking arena, specializing in medical-service companies. and during this time became an officer and director of Informed Care, Inc. specializing in disease management programs.

In 2008 Dr. Kenton was the founder, Chairman and Chief Executive Officer of Best Practice Disease Management, Inc., providing health risk assessments and preventive disease services for insurance carriers. After achieving his goals and navigating the company to a successful acquisition set his focus on addressing healthcare issues to a larger national level.

Dr. Kenton co-founded Novus Healthcare, Inc utilizing the programs he helped develop over the last 15 years, to form a healthcare company that not only is able to document and accurately measure the state of health of the patient, but also provide cutting edge disease management services to patients as a means of improving their quality of life while also greatly reducing the costs associated with chronic illness. His Doctorate is in Business Administration.