020 - Money Tree Series #4 - The Specialists

December 16, 2021 Coach JPMD Season 1 Episode 20
020 - Money Tree Series #4 - The Specialists
Show Notes Transcript

In this Money Tree Series Episode #4, Coach JPMD talks about the role of the Specialist and their influence on the Money Tree. He discusses how they impact the flow of funding within the insurance and within the IPA. He talks about the relationship between local Specialists and Primary care physicians. He discusses the importance of communicating regularly with the specialists in order to deliver the best patient care. The Money Tree Series Podcast episodes are geared toward helping physicians and other healthcare providers with the ins and outs of running a successful Medicare Advantage practice.  You can download the money tree diagram at

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Show Notes 

Intro  0:00  
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  0:26  
Welcome, welcome. Welcome. Welcome to the Practice Impossible Podcasts. Thank you for listening. I'm your host, Coach JPMD. And before we start this episode, I wanted to encourage you to leave some feedback for me, leave a review on Apple podcasts or wherever you listen to your podcasts, because that is the only way I'm going to know what you want to hear. And if this is resonating with you as physicians or health as healthcare providers in the community, and we want to serve you and we want to provide the as much value as we can in these episodes. So today's episode is actually on the money tree. It's part of the money tree series that I started back in October of 2021. For those of you that are listening in 2022 or beyond, and I have a confession. And my confession is I think I bit off more than I could chew in the saying that I want to offer this money tree series every week, because I just ran out of time. And so I'm going to be inserting the money tree series into our bi weekly releases of our podcast. So that's why you haven't heard a Money Tree series in a couple of weeks. So that's my confession today because I thought I could potentially keep up. But with the practice and with things happening in life, I found it a little bit more challenging than I thought. That said, I do want to continue the money tree series. And today, we're going to be talking about specialists and how specialists and what role specialists play in that money tree. We've discussed money tree several times. And that can be downloaded at And just to give you an idea of what I'm talking about, because it keeps saying this in our series and it kind of depicts the flow of monies from Medicare to specialist pockets or primary care, physician pockets or hospitals, pockets. So we've talked about how the government is funded through tax dollars. We talked about how the insurance companies receive monies through CMS. And then we talked about IPAs and how they distribute monies to health care organization’s. So today we're going to talk about specialists and and really how they impact the flow of funds within an insurance and IPAs pool of funding. So when we talk about specialists, we talk about podiatrists, we had Dr. Jude Farley Pierre, who's a podiatrist friend of mine who on the podcast a couple weeks ago, and if you haven't had a chance to listen to that, you know, he talks about some of the things that we talked about in the payment tree and the IPAS and, and I encourage you to listen to that episode. And that episode is episode 19. And then you have cardiologists who are contracted to provide services for healthcare organization’s and Medicare Advantage companies have pulmonologists, who have hospitalists who have neurosurgeons you have hand surgeons, you have plastic surgeons. And so all of these specialists contract to provide care in a network of physicians in a particular county. So you may have heard of the term out of network providers or in network providers. And a specialist in order for them to, to accept payments, or even to see patients part of payments from a Medicare Advantage company, they have to be in network. So they have to credential with that particular HMO or that Medicare Advantage company in order to provide services. And those services are usually rendered on a fee for service basis. So they see the patients and they provide a or they complete a surgical procedure. And they receive monies from the health care plans or the Medicare Advantage companies. Now as a primary care doctor, it is my job to somewhat be the gatekeeper for those funds. And, and there are specialists that provide care that are that's cost effective. And then there's their specialists that don't. And after practicing for 20 years, and developing a strong network of specialists in our area, I tend to understand who can provide cost effective care and efficient care for for my patient population. And I tend to refer patients to those specialists.

One of the beauties of having a network of specialists in your county in your area, so that you develop relationships with them. And so if you have a patient with, let's say, dysphasia that can't swallow or having difficulty swallowing solids, you know, I've, I've routinely called my GI specialist, and he's been able to see my patients within within a day or two. And having those types of relationships really helps patient care, and also decrease costs. Because if those patients are not seen in a timely fashion, then they'll end up in the emergency room, which will eventually cost you more in caring for that patient. And so that's typically in a fee for service contract. But there are specialists, like podiatrists like my friend, Dr. Jude Farley, Pierre, who receive a flat fee for managing patient populations through an IPA. And I can't remember if he was actually doing that, or a podiatry group that he was in was doing that. But insurance companies can contract with specialists who have a group of providers, for which they then receive monies, let's say on a capitated basis. So they receive the same set the same amount of money every month per patient. And that enables them to kind of predict what their income is going to be. And also decrease the need for billing for individual services and hiring billing staff to code for particular procedures. Because, you know, the procedures that are performed are apart of that arrangement, part of that capitation fee. So the billing is a little bit simpler, or the billing is simpler in terms of collections.

So in creating this episode, I wanted to highlight three things that specialists can do to practice impossible. And one of the main things is that they need to know the markets. There are some specialists who don't understand that if there you go, they go into a community where there are not a lot of specialists, like neurosurgeons or hand surgeon, plastic surgeons, they can negotiate higher rates, to be able to enter and provide services in that county. So that's one thing. The other thing is, you want to be friend, the high volume PCPs, there are a lot of primary care physicians that may not be as busy in a community, but those that are busy are going to send patients to cost effective and efficient specialists. And we try as primary care doctors to decrease hospitalizations and decrease the emergency room visits. And to do that you need a good strong network of providers that are going to provide care, same day next day. And that allows patients to get the best care I feel, particularly when patients can get very anxious about certain medical conditions.

And the third thing that I would recommend that a specialist too, is diversify. So I don't feel that it's a good idea to just focus on one insurance company, a specialist should have multiple insurance payers that they they contract with so that they can diversify their income, just like diversifying your portfolio and your 401k or your investments. Because, you know, if that one HMO that one Medicare Advantage company doesn't do well, then that could affect your your revenues. So know your market, know your worth, know your value in that market, befriend the high volumes PCPs because they will send you patients and they will refer patients to you and diversify. So you guys might be wondering, why does this does this all matter? It's interesting, because last week, or a couple of weeks ago, I took a took a week off and had the TV on during the daytime hours, and I usually don't but I had the TV on just for noise purposes. And it was almost as if every other commercial had a celebrity promoting Medicare Advantage plans. From Joe Montana, to William Shatner, to George Foreman, to even JJ, JJ Walker, I don't have audiences old enough to know who JJ is, but love JJ. And you can look them up if you want to. But you know, so the these are all celebrities promoting Medicare Advantage plans to seniors, because I guess most of them are watching TV during the day. And I kept wondering, as a physician, we should know everything we need to know about Medicare Advantage plans because they're being promoted so much, especially during the open enrollment period, which I believe ends December 7. So after December 7, you you're kind of locked in to a Medicare Advantage plan as of January 1. So if you are in a population where there's a large Medicare Advantage population and you're practicing medicine, and you're seeing patients over 65, you kind of really need to know what's going on in the Medicare Advantage world because it is being promoted in the community. It Now, you know, Medicare Advantage is penetrated 30 over 35%, I think almost 40% in some of the numbers that I've seen of patients enrolled in a Medicare are in a Medicare Advantage plan. So we, as physicians, and providers need to understand this well, and so that's why I created this money tree series. I want to be able to provide that information for you. This was a kind of a short episode, but it is an episode that I think you know, it kind of follows the the payment tree and the money tree that I've created. And if you want to hear more, if you want me to go in more in depth in some of these topics, leave a review, visit Tell me what you think. And we'd love to be able to create more episodes like this or not, but I only can do that if you tell me. So, thank you again for listening. And don't forget to share this with your friends and your colleagues. Because that's what's going to get the word out that this exists and hope you guys have a great holiday season.