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Physicians Dropped by Health Plans for Overutilization


For Medicare to survive and to decrease healthcare costs in this country, healthcare delivery needs to change.

After United Healthcare dropped 15 percent of its provider panel, I was not surprised. I actually thought something like that would occur sooner. It is clear that for Medicare to survive and to decrease healthcare costs in this country, healthcare delivery needs to change. Most believe that fee-for-service reimbursement is no longer an option and there seems to be a shift toward pay for performance. Clearly, increasing quality, decreasing costs, and increasing patient satisfaction are goals both payer and provider would strive for.

There are certain services in place to help meet these goals. One such example is the Medicare Annual Wellness Visit (AWV). The AWV, by delivering evidence-based preventive services, helps keep patients healthier and prevents over-utilization of services. The visit also helps satisfy quality measures for PQRS reporting. Despite all these advantages only approximately 12 percent of Medicare beneficiaries have had their AWV.

Another way to increase quality and decrease costs is to identify those patients that are at increased risk of overutilization. The current methodology to identify risk is the CMS HCC method. In addition to identifying risk by assigning a risk score to each patient, the codes are necessary for Medicare Advantage (MA) plans to get paid from CMS. The majority of physicians do an incomplete job of coding, making it necessary for MA plans to use third-party providers for risk assessments and retrospective chart reviews. There are now automated software solutions that provide all the components of the AWV and calculate the CMS HCC risk score real time.

The point is that fee-for-service overutilization, no coding, and not providing quality measures will not be and should not be tolerated. Those plans with strong executive leadership will identify those top 15 percent physician over-utilizers and not allow them to participate in the MA plan. If I was one of those executives I would make the same decision. It is time to make the paradigm shift and provide the highest quality care as cost efficiently as possible. It is to the providers' advantage to provide wellness visits for all their Medicare patients, and to understand the nuances of HCC coding.

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