Anybody There? Physicians Unfairly Penalized for AWOL Medicare Advantage Patients
By Joey Berlin Texas Medicine August 2019


You’ve tried and tried and tried. Phone calls, emails – nothing.

A Medicare Advantage plan assigned you a patient who didn’t choose you, and the patient is driving that point home – by ignoring you. Or maybe the contact information the plan gave you is out of date, and the patient’s latest phone number or email is unknown.

Either way, your as-yet-unseen patient is AWOL – and you can be penalized for it on health plans’ quality ratings, which ultimately can affect payments.

That can and does happen, says Kingwood family physician Maria Berdayes, DO, who sees a high number of patients on Medicare Advantage plans. The vast majority come in when they’re supposed to. But in any patient panel, Dr. Berdayes says, there’s a small percentage who just aren’t reachable.

“You have about 5% of the population that just doesn’t want to do anything,” she said.        

New Texas Medical Association policy takes aim at the unfairness this lack of patient response can present for physicians, while opening up an opportunity for medicine to work with health plans to solve the problem.

Unfairly penalized

At TexMed 2019 in May, TMA’s House of Delegates adopted policy that supports:

  • Medicare Advantage plans allowing primary care physicians to remove patients from their panels if the physician proves he or she has made repeated attempts to establish a patient-physician relationship; and
  • Leaving untouched physicians’ Healthcare Effectiveness Data and Information Set (HEDIS) ratings, as well as other quality scores or ratings, if the physician was unable to establish a relationship despite “multiple documented attempts.”

When proposing the policy, the Harris County Medical Society (HCMS) noted how time-consuming and costly it is for physicians to remove patients from their panels. In some cases, a plan will require physicians to send certified letters to these patients.       

Assigned patients affect components of the HEDIS ratings that reflect physicians’ performance on annual preventive visits, breast cancer and colorectal screenings, and medication adherence, HCMS wrote. Medicare requires HMOs to report on HEDIS measures, which affect the health plans’ star ratings and in turn can affect bonus payments the health plan may offer physicians based on their HEDIS performance.

For instance, non-responsive patients “do go against your HEDIS measures when it comes to ones that are just based on age and not a diagnosis,” said Dr. Berdayes, president of Alliance ACO, one of the accountable care organizations TMA PracticeEdge formed to help primary care physicians and patients reap the benefits of value-based care.

Additionally, “some of these patients [are] constantly in the hospital, and when as a [primary care physician], we reach out to them to get an appointment, some of them won’t come in for follow-up,” Dr. Berdayes added. “That’s difficult, if you can never get them back in, and they just keep going to the hospital.” 

An evolving process

Dallas family physician Christopher Crow, MD, sees the adopted policy as an opportunity for TMA to emphasize the importance of every patient having a primary care physician, while working with insurers to make sure that can happen without physicians being unjustly penalized.

“Rather than just state the problem and say, ‘Go fix it,’ or, ‘Throw it out; don’t penalize me for that,’ I think we need to take a … creative [approach],” said Dr. Crow, president of the Catalyst Health Network, a clinically integrated primary care network. “We understand that it’s always going to be there. We understand that just throwing it out doesn’t necessarily help the situation. So [let’s figure out], how can we be a co-creator and evolve the system for good along the way?”

As for next steps, Drs. Berdayes and Crow both raise a key question that would arise if physicians could “fire” HMO-assigned patients for not being reachable.

“The question for the health plan is … where do [patients] go? What happens then?” Dr. Crow said. “Because by definition, they have to be assigned to somebody. So what do we do with that data?”

It also remains unclear just how willing commercial insurers will be to work with medicine to address how to handle these patients. Texas Medicine reached out to several health plans and the Centers for Medicare & Medicaid Services for a reaction, but none provided comment.

Tex Med. 2019;115(8):36-37
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Last Updated On

September 04, 2019

Originally Published On

July 29, 2019