Remodeling Insurance

Insurance companies have a proud tradition of adopting misguided payment procedures which have unintended consequences.  One of the most glaring examples was their 1970’s doctrine of refusing to pay for outpatient surgical procedures.  They reasoned that if a designated procedure was not significant enough to require hospitalization, it did not merit insurance reimbursement.  That unfortunate logic cost them billions of dollars in payment for unnecessary hospitalizations.

They continue to make similar mistakes to this day.  The doctrine of paying a surgeon in full for a primary procedure but only 50% for a second procedure during the same operating room visit creates a powerful incentive for the surgeon to admit the patient more than once when a combined procedure would be more cost effective.  How many opportunities to complete a bilateral inguinal hernia repair have been split into two separate hospitalizations as a result?  Millions of dollars are wasted.

The primary care physician is likewise incentivized to see a patient three separate times if diabetes, hypertension, and COPD each need attention.  One properly compensated office visit would be a much more efficient way to care for this patient’s problems.

As its name implies, the Flagship Physician Network is an organization of physicians.  We are developing a community healthcare system that understands the needs of the patient and the needs of the physician.  Most importantly, we are in a position to design the insurance coverage to be efficient.  We must have a starting point, and that starting point will be developed from the traditional policies we have available to us.  But from there, we will apply our knowledge to modify and improve the package.  When you, as the practicing caregiver, see opportunities to make improvements, your input will be considered and will have an impact on the compensation system.  We are ready NOW to begin receiving your suggestions and opinions.  We also invite our non-physician readers to give us input.  Hospital administrators, office managers, businessmen, our insurance friends, and especially those who have been patients have special insights that can make a real difference.

Forty years ago, physicians were told, “If you don’t fix the system, somebody will fix it for you—and you won’t like it very much.”  Oh, how prophetic that was.  We are sick and tired of seeing “cost containment” implemented by reducing physician compensation.  This is our insurance plan, and we have the opportunity to directly impact its structure.  It’s time for us to fix the system.

DO NOT ASS-U-ME that the necessary changes should be obvious.  We are soliciting your input, and we need to hear your suggestions.  Help this organization work for you!

Critical 7 Weeks for PCPs

Dear Primary Care Provider:

As previously communicated, I am excited to assist PDA with Medicare marketing efforts during this Annual Enrollment Period (AEP) through December 7.  Specifically, this is the yearly opportunity to increase the size of your Universal American (TexanPlus) patient panel.

Please contact me now so that we can discuss your specific marketing needs.  Also,any patients who inquire about their Medicare choices should be referred to my cell number or the PDA office at the contact information listed below.

I look forward to a successful and profitable working relationship with each of you.

Warmest Regards,

Lisa A Wilson



Introducing Lisa Wilson

We have reached to the Medicare-sophisticated market of Florida to recruit Lisa Wilson.  She is an experienced and articulate executive-level sales director with specialized industry knowledge of Medicare and Medicaid. Ms. Wilson brings a professional knowledge of managed care regulations and compliance requirements with a verifiable record of double digit sales increases. She also has directed direct marketing and call center lead generation for Medicare Advantage and Medicare supplement companies. From 2007 – 2011, she was State Director of Marketing and Sales for QUALITY HEALTH PLANS, INC., Tampa, FL. That experience is here for this critical once-a-year run for members.

Medicare regulations dictate a right way and a wrong way to build your Medicare Advantage practice component.  PDA staff resources and the agency brokers have obtained special certifications to market this product. Yes, that means required study and a test score achievement. That know-how is joined with expert knowledge of the Center for Medicare/Medicaid Services (CMS) marketing guidelines and regulations including agent oversight and monitoring.

Lisa Wilson has answers for you and your office staff that will drive the interest of Medicare-eligible persons to select TexanPlus by Universal American.  Please welcome her and reach out for the revenue benefits which are inherent in the plan we are representing. A blog is not the appropriate place to present all the “What’s-in-it-for-me$”.  If you accept Medicare patients, you need to understand the PDA product rewards and responsibilities.

First come, first served!  Call 972-484-5889 or Lisa Wilson’s mobile at 407-473-0000 to schedule an appointment.

Immediate Medicare Advantage Opportunity

We are all about making more revenues for our physicians.  The shrinking income of independent primary care practitioners represents a critical concern for PDA. This concern is a priority as the cost of operating a small business and practice regulations continue to increase. We believe that this is a global PDA priority for everyone.  As PDA achieves its mission of being the fortress for productive PCPs and Nurse Practitioners/Physician Assistants, there will be an enviable volume of referrals in the system for our specialists.  We get it.  PCPs are the coin of the healthcare realm. And, we are doing everything we can to create revenues to counter their declining managed care reimbursement.

A major current revenue thrust is Medicare Advantage plan marketing.  First, we seized a competitor’s first class Medicare Advantage product.  Then, we secured an exclusive arrangement with the insurer.  Our plan is to do one Medicare Advantage plan really well rather than 15 poorly. To that goal, we have our Medical Director immersed in medical management training.  Our medical director, Daniel S. Karin M.D. is committed to creating a new level of medical management coordination and training for all our practitioners.  Also, the administrative aspect has been streamlined and positioned to deal with increasing volume.  We are working hard to learn the path to Medicare Advantage excellence.

With a foundation being firmly developed, the new PDA Medicare Advantage emphasis is designed to jump-start growth with marketing.  And, we just located a tremendous marketer.  An organizational announcement will follow. The marketing function is unbelievably important as we have a very small window to recruit new plan members.  Many managers believe that the small, restrictive window to recruit new Medicare Advantage members is just another indication that the current administration is endeavoring to steer to a single payor system versus the option of competition-based healthcare delivery.

We are counting on the energy of our insurance agency component to deliver a large number of new patients.  Operations Manager James Martin and other staff are working to enlist physicians that are now directly contracted with Universal American to improve their entire rewards system.  Only by interfacing with TexanPlus thru the PDA portal can PCPs maximize their Medicare Advantage revenues.  The PDA challenge is to communicate effectively that the IPA option is so dramatically better.  If one takes care of TexanPlus patients, PDA can show that the best reimbursement is through PDA membership.  This message is very timely as the window is:

October 15th through December 7th.

That’s it… forty-five days for the Annual Enrollment Period!

Mobile Services Now Provided by PDA

The Flagship Network is pleased to introduce you to mobile diagnostic testing. We have contracted with Imaging Resource Centers, Ltd.(IRC) to provide (1) mobile bone density, (2) diabetic retinopathy and glaucoma and (3) EMG/nerve conduction testing services. All diagnostic testing will be provided as a convenience to your patients at your office. Please find a brief description of the services in the following information.  Ed Young CEO of IRC, and Mr. Dave Varnell will be calling to introduce themselves and to schedule a time with you to discuss the services and your reimbursement.  Please welcome your local IRC representative. PDA management has reviewed these offerings and is excited to provide you with these exciting new revenue opportunities.

 Bone Densitometry

Osteoporosis afflicts an estimated twenty-four million Americans, resulting in more than one million hip, spine, and wrist fractures annually.  This disorder affects one-third to one-half of all postmenopausal women, one of the groups at highest risk.  Bone Densitometry assists in the diagnosis of osteoporosis evaluation of response to treatment. IRC will provide your office with bone density scanning capabilities via a mobile vehicle. The service will also include a certified radiology technician. Your patients can now receive a state-of–the–art bone density test in the convenience of your office.

Diabetic Retinopathy Testing

Early detection of retinopathy is critical to prevention, yet fewer than 50% of all diabetic patients have an annual eye examination.  IRC’s retinal photography can detect early damage to the retina caused by diabetes, glaucoma and other conditions.  It is non-invasive, requires no dilation and it obtains exceptionally high quality digital images of the retina using a fundus camera.  This HEDIS compliant solution provides a simple, affordable pathway that allows physicians to capture their patients’ retinal images during a three to five minute procedure. Images are transmitted over a secure, HIPAA compliant network to an accredited reading center.  A state-licensed and board-certified eye care specialist reviews the images and results are returned to the physician within five business days.

IRC will provide a fundus camera, tonometer, and technician so you can offer diabetic retinopathy services in the convenience of your office. This effective pathway will bridge the gap that may exist between diabetic patient eye care compliance and general diabetic wellness.

Nerve Conduction and EMG Services

Some common types of neuropathies are Low Back or Leg Pain, Diabetic Peripheral Neuropathy (DPN) and Carpal Tunnel Syndrome.  Nerve conduction and EMG studies are the gold standard for diagnosing neuropathies and they allow for a treatment plan to begin quickly.  IRC will provide the nerve conduction / EMG equipment, a technician, and neurologist to provide the services. The testing will take place in the convenient and comfortable surroundings of your office. The procedure involves delivering a small electric pulse at one point on a nerve and measuring a response at another point.  Results are available quickly so the physician can begin a treatment plan.

PDA is focused on improving physician revenues with no additional hassle or extra time commitment.  We are alert to new procedures which contribute to high-quality cost-effective medical care.