The Verden Group

Physicians Contract with Self-Funded Employers


Pearl | October 28, 2015 | Payers, Patients, Pearls, Physician Compensation, Revenue Cycle Management

By Susanne Madden

Originally published at:

Some medical practices are cutting out insurance companies and providing services directly to employers (direct care), thereby reducing overhead and cost to patients.

First, let me define what is meant by “direct care.” Similar to charging patients cash for your services, the difference here is that you are charging employers directly for services delivered to their employees. There is no middle-man insurance company; simply two parties exchanging cash for services. So “direct” here means that you, the physician, are selling your services directly to the purchaser of healthcare, the employer.

This is not as novel an approach as you might think. Employers, particularly those that are “self-funded” (meaning those that carry the financial risk for employee claims rather than the insurance company), have already been investing in medical tourism for years. They contract directly with providers of care overseas (or through medical tourism companies) and send employees for such services as bariatric surgery, knee and hip replacements, and hernia operations, which are far less expensive than here in the United States. Even some insurers, like Anthem Blue Cross and Blue Shield, are exploring the idea of including medical tourism as a part of their coverage.
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The Potential of Patient-Centered Specialty Practice


PearlSeptember 02, 2015Practice ModelsHealthcare ReformPatientsPearlsPhysician Productivity


What is PCSP?

Patient-Centered Specialty Practice (PCSP) is a recognition program from the National Committee for Quality Assurance (NCQA) that went into effect in 2013. The PCSP program was designed in many ways to complement the success of NCQA’s Patient-Centered Medical Home (PCMH) program and expand its reach. The goal of the program is to encourage excellent care coordination by specialty practices in the outpatient setting, leading to less duplication of procedures and fewer hospitalizations.

Much like the PCMH program, the PCSP program focuses on proactive coordination of care, information sharing among clinicians involved in a patient’s care, and a centering of care around the patient (versus around the care setting).

According to the NCQA, “Specialists who achieve NCQA PCSP Recognition will show purchasers (consumers, health plans, employers and government agencies) that they have undergone a rigorous and independent review to assess their capabilities and commitment to excellence in sharing and using information to coordinate care.” What this means practically is that practices that undergo the process will be better placed to meet the challenges of the marketplace.

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Building Effective Patient Education Programs


PearlApril 22, 2015Patient RelationsACOHealthcare ReformPatientsPearls

Patient education programs have been around for a long time, but typically these programs have been geared toward only the chronically ill and those that needed extensive management. In this era of the Patient-Centered Medical Home patients and insurers are looking more to physician practices to provide effective patient education in all aspects of their care. In fact, many insurance companies are actively measuring physicians’ performance on quality metrics. Current accountable care models factor in patient utilization of emergency rooms, hospital visits, and prescriptions, and attribute that cost to the patient’s primary-care doctor, which may also include specialties such as cardiology.

So what does this mean to your practice? With more accountability comes the need to manage patient populations more effectively to be able to hold the line on costs. If you are not doing a good job in actively engaging patients to “self manage” their own care, and utilizing lower-cost opportunities for managing your patients’ care, then you may soon find yourself failing to achieve a targeted level of care and cost utilization, and that will cost you money.

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Independent Integrated Networks: What You Need to Know


Pearl | July 01, 2015 | Practice ModelsPayersPearlsPerformancePhysician Compensation

Many physicians are by now familiar with such terms as “clinically integrated networks” (also known as CINs), but a slightly different model is beginning to emerge as independent practices resist being swallowed up by hospital systems, and physician organizations become more savvy. You can think of this model as a hybrid between the “super group” (or clinically integrated practice) model and the more familiar hospital-based offering whereby care coordination and data is managed centrally there. Rather, these independent integrated networks (IINs) are being driven by independent physician organizations, coalitions, and alliances between physicians themselves.

What is “clinical integration” anyway?

The Department of Justice and the FTC define clinical integration as an active and ongoing program to evaluate and modify practice patterns by the CIN’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. Generally, the FTC considers a program to be clinically integrated if it performs the following:

1. Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care;

2. Selectively chooses CIN physicians who are likely to further these efficiency objectives; and

3. Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.

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State Pediatric Medicaid and CHIP Medical Home Initiatives: At-a-Glance Table

statemapThe National Center for Medical Home Implementation (NCMHI), in partnership with the National Academy for State Health Policy (NASHP) has created a state at-a-glance table which provides an overview of pediatric medical home initiatives occuring through Medicaid and the Child Health Insurance Program (CHIP).

By learning about ongoing pediatric medical home initiatives in your state, pediatric clinicians, practices, state Title V agencies, American Academy of Pediatrics chapters, and others can gain insights on how to integrate their work and coordinate efforts across multiple systems.

Click here to view or download the state at-a-glance table.


Forming a Medical Practice ‘Super Group’


Pearl | September 03, 2014 | Practice ModelsManagers AdministratorsOperationsPearlsReferrals

We have seen an enormous consolidation in medical practices across the industry in the last three years. Many practices are being bought out by hospital systems in preparation for laying the groundwork for accountable care organizations and for building market share in the new value-based purchasing environment.

But rest assured, the independent practice is alive and well — there are practice models available that allow physicians to operate independently, while coming together as one entity to reap the benefits of cost efficiency. One way physicians can reinvent their practices, is to become a “super group.”

Looking for more ways to boost performance at your practice? Join experts Rosemarie Nelson, Lucien W. Roberts, Owen Dahl, and others as they help improve your medical practice and your bottom line atPractice Rx, a new conference for physicians and office administrators. Join us Sept. 19 & 20 in Philadelphia.

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Patient Portals Can Help You Meet Medical-home Criteria


Pearl | October 08, 2014 | Patient PortalsMeaningful UsePatient RelationsPearlsPractice Models

If you are thinking about implementing a patient portal, or already have one in place, you may not realize that this is a great tool to help you meet certain criteria necessary for achieving Patient-Centered Medical Home (PCMH) recognition.

Many portals offer the components required to meet part of the National Committee for Quality Assurance’s (NCQA) PCMH Standard for patient-centered electronic access. The purpose of doing so is to allow the practice to offer information and services to patients and their families via a secure electronic system whereby patients can view their medical record, access services, and communicate with the healthcare team electronically.

Providing electronic access to this information also enables practices to meet meaningful use requirements, so you get a double return on your portal investment if you are attempting to meet requirements for both the NCQA PCMH and meaningful use programs.

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New Practice Models Are Gaining Acceptance in Primary Care


August 20, 2014 | Great American Physician SurveyPatient RelationsPhysician CompensationPractice ModelsWork/Life Balance

Manhattan cardiologist Arthur Weisenseel has enjoyed a long and satisfying medical career; one that encompassed teaching at New York-based Mt. Sinai Hospital, running a successful cardiology practice with another physician, and stewarding his aging patients into a healthy old age. But, somewhere in the last five years to 10 years, his practice became problematic. Weisenseel says that despite working as hard as he could, he wasn’t able to consistently pay both practice expenses and himself. He says of that time, “I worked awful hard to get [there]. And to go home without reimbursement was becoming demoralizing.”

So, like a growing contingent of like-minded physicians, Weisenseel decided to explore other practice models. Encouraged by his patients and positive conversations with colleagues, he has now successfully converted his practice to a hybrid-concierge model, where patients can choose to pay an extra fee for concierge services or continue to reimburse him through traditional insurance plans like Medicare and third-party payers. Now he couldn’t be happier: Relieved of worries about financial and regulatory burdens, he says, “I come to work with joy and confidence.”

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Patient-Centered Specialty Practice for Specialists


While still in its infancy, word about the National Committee on Quality Assurance’s (NCQA) medical home program for specialists is spreading fast. The program was released last March and appears to be gaining considerable momentum. We receive inquiries daily from practices asking how we can assist them with meeting the program’s standards; from gastroenterologists, oncologists, nephrologists, orthopedists, even ophthalmologists.

Unlike the primary-care Patient-Centered Medical Home (PCMH) program that has taken several years to become firmly established, it appears that specialists are “early adopters” of this new similar program — Patient-Centered Specialty Practice (PCSP) — designed especially for them.

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NYS Insurance Price Wars


One of the puzzling questions about the Health Insurance Exchanges (a key component of the Patient Protection and Affordable Care Act) is, “How can the same products have such variations in premium pricing?” Differentials of between $200 and $500 a month are noted for the same metallically labeled products.  Why the difference? Answer: the insurance carrier.

The lowest prices have been associated with the newest entrants into the NY market, Heath Republic and OSCAR. The established payers, such as Empire and, in particular, United Healthcare, were priced at the high end.

Since all products are essentially the same in terms of benefits, the difference would be in the costs of the network that supports the payer’s product and the pricing philosophy of the company.

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