005 - Are You IN or OUT? Is a Medicare Advantage Practice for You?

June 17, 2021 Coach JPMD Season 1 Episode 5
005 - Are You IN or OUT? Is a Medicare Advantage Practice for You?
Show Notes Transcript

In this  solo episode, Coach JPMD details some of the differences between fee for service plans and Medicare Advantage plans.  When he first started his practice in Spring Hill, he was often met with disdain from other colleagues in his community about who he worked for.  Many physicians do not understand the revenue opportunity in caring for our senior population.   Coach JPMD realized early on in his career that there was a tremendous opportunity to earn a great living seeing patients under a Medicare Advantage plan.  These practices are not for everyone and learning the differences between typical fee of service practices and Medicare Advantages practices can help you decide whether you are in or out.  You will not want to miss this episode.

Show Notes

Intro 00:00
Welcome to the Practice: Impossible podcast where your host Jude A. Pierre MD, also known as Coach JPMD, discusses medical practice topics that will guide you through the maze that is the business of medicine, and teach you how to increase profits and help populations live long. Your mission, should you choose to accept is to listen and be transformed. Now, here's your host, Coach JPMD.

Coach JPMD 00:24
Welcome, welcome. Welcome. Welcome, again to another episode of the Practice: Impossible podcast. And today I'm going to ask the question. Are you IN or are you OUT? Is a Medicare Advantage practice for you? So I'm going to begin this episode by saying something that was said to me in 2002, and that was, "Oh, you work for that HMO doctor?" I had just started with Access Healthcare practice that I'm actually working with now. And Dr. Singh was managing a large Medicare Advantage practice.

He quickly became a mentor friend and someone that I really trusted in the Medicare Advantage space. Because I had no idea what I was doing. I had come into Spring Hill, with the knowledge of Fee for Service. I had been working in the emergency room and downtown in the emergency room in Miami. And all I knew was Fee for Service. All of my professors, and my mentors, and doctors who I worked with in Miami had really only been doing Medicare and or commercial insurances. And I came in thinking, "Hey, I'm going to need to see X amount of patients per day, and I'm going to get reimbursed a certain amount of money. And that's, that's how I will grow my practice and make my salary". And that's really the typical way that most physicians receive monies in their practices.

They see the patient under contracted plan, they get paid in 14 days if they're lucky, and patients could change PCPs anytime. So as a primary care provider, if a patient doesn't like your office, or if something happens in the office, that doesn't please them, or they change insurances, and you don't accept that particular insurance, then that patient will no longer see you. Those same patients can also see specialists without any PCP involvement. And that's something that always kind of irked me because some patients would see a specialist and a specialist wouldn't send their notes to me. And when I see the patient upon, you know, a follow-up visit, they say that they had certain procedures done, and I really had no clue as to what happened.

And even today, I think this is how probably over 80% of physicians get paid. And that is, they see patients under contracted plan and they receive monies based on that contract. And this is how things work in medicine, but not that HMO doctor. You see, that HMO doctor that I was laughed about joining mainly saw patients under Medicare Advantage plan. And those plans, that he was contracted with, received money from the government. And those monies were distributed to through an IPA or Independent Physician Organization or Association. And with that, Medicare Advantage plans contract with health care providers, PCPs, specialists, hospitals, nursing homes, radiology centers, they contract with all these providers, and are given a pool of money to care for that patient population.

So those groups of providers, in particular the group that I joined, manage the care of a large population of patients. And what's unique about this arrangement is that as a primary care provider, we receive monies on a monthly basis, that's called a capitation check. And that check comes in regardless of whether or not we see the patients. If we take care of the patients well, and if the patients stay out of the hospital, and they're prescribed generic medications, and they receive or go to in-network providers, there may be a bonus that is distributed amongst the IPA as well as the physician office. And these bonuses can be fairly lucrative, depending on the contract that you signed with the particular Medicare Advantage plan.

So one of the things that instantly jumped out at me was the fact that if you are a physician that cares for your patients, and that is responsive to your patients, then those patients become very loyal to you. And because they're part of a Medicare Advantage plan. It is not common for those patients who are satisfied with their primary care doctor to switch doctors. So it's not like a Fee for Service plan where that patient can go to any provider, because they're not tied down to that Medicare Advantage plan. For many of the Medicare Advantage plans, particularly the ones that are managed through capitation arrangement, and which is also called Risk Arrangement. Specialists usually have to send authorization requests in order to see patients under a particular PCPs panel. And with that, you're instantly involved in the patient's care because the specialist then has to send consultation notes in order to receive that authorization.

Now, I mentioned earlier that bonuses can be distributed for caring for patients in a cost-effective manner, but one of the things that can be done to help supplement your practice with bonuses is by decreasing hospitalizations, decreasing emergency room visits, and increasing preventative care measures. Those are all equal to an increase in revenue. Another thing that is pretty neat about Medicare Advantage plans is the predictability of income. So if you have a panel of 400 members, 500 members, and you're receiving a set fee every month for those members, then you're not having to worry about seeing a number, say 25 patients 30 patients a day, in order to make the income, that income is going to come to you regardless of whether you see the patients or not.

Now, can it be risky? Yes. That's why it's important to understand what you're doing in the managed care world as a physician, as a primary care physician in particular, because there are some patients that will increase or will go to the hospital or will go to the emergency room frequently. And it's up to you as a primary care provider to implement things in your office that will help decrease the chances that your patients are going to end up in the hospital. And that's just with frequent follow-ups and communication with your patients. And just making sure that you manage the high-risk patients and the patients with complicated chronic medical conditions in a cost-effective manner.

Using all of your resources, including the insurance company that can help you with some of the chronic patients with resources, such as home health care, social services, transportation, and these are some of the things we can help teach you how to manage in a cost-effective manner. So one of the things I like to say that we're like in any managed care world, is, if you do manage care, well, you become like a concierge medicine physician for your patients in your panel. And some of my patients have my cell phone number. And I tell them to call me if they have a problem or if they're having difficulty getting the office to do things or if they have a question or a concern because that one phone call can save an admission to the hospital.

Especially if the patient has difficulty getting to the office due to their medical problems. So as I've said in previous episodes, this is what I do. This is what I've been doing for the past 20 years. And with the help of mentors like Dr. Singh who helped me start off in Medicare Advantage and several other mentors that I've had over the past couple of years. I've really learned how to manage a Medicare Advantage population well and I've hired physicians and nurse practitioners that have also gone on to really run successful practices of their own. Now I'm far from perfect, and there are lots of things I'm still learning as we go along. But so this first season in the Practice: Impossible Podcast is really dedicated to helping providers know the differences between Medicare and Medicare Advantage plans, and what you can do to really Practice: Impossible.

You can do it, I'm living proof that you can do it. And I know many other physicians that I've done Medicare Advantage, and I've done it well. And what I've done is provided tools that can help you. You can download a free report that I've created that details the differences between Medicare and Medicare Advantage at And if you scroll down to the bottom, you'll find the link to the free report. And you can also sign up for our free course on Medicare Advantage plans and that's at So, if you want to hear more episodes about Medicare Advantage plans and how we can together help populations live on by increasing awareness then subscribe, share this podcast with your friends, leave a review that's how we get to get the word out and how we can help our colleagues Practice: Impossible

Thanks for listening, and we'll see you soon