Centers for Medicare & Medicaid Services (CMS) Bundled Payments

[AnnaLee]

Has this or something similar happened to other Medicare A&B primary participants? My husband, age 75, is in the hospital having developed a case of pneumonia. He has advanced Parkinson's so pneumonia can be life threatening. Yesterday I received a letter from a physician’s group I never heard of before, "Sound Physicians". The letter begins with: "We wanted to let you know that your health care provider, Sound Physicians, has volunteered to take part in our Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement Advanced Model (BPCI Advanced). " I can provide the rest of this letter if you want to see it.

How can an outfit I've never heard of before be my "health care provider". My insurance is through Medicare with GEHA as secondary. I cannot find that this organization runs the local hospital or it's ER. Neither I, nor my husband, have given this organization or anyone claiming to be a part of this organization permission to bypass CMS and manage our healthcare. So, CMS must have let this happen without our knowledge. Can they discriminate against a selected few that are getting old and sick by dumping them into private, for-profit, cost centers run, presumably, by high paid hospitalists? I checked this is a CMS innovation program in its experimental phase.

Good grief, he is a sick man, not a guinea pig. Has anyone else received an announcement that they were placed by Medicare into an experimental management program for "better care at lower cost". When your loved one is in the middle of a medical crisis, it feels like CMS decided to see if they can kill the old man.
https://innovation.cms.gov/initiatives/bpci-advanced/

[SheltieLover]

1. Sorry to hear your husband is so ill. Healing vibes on the way to him. 💓💓💓

No idea about this issue.

Call hospital billing & Medicare to inquire!

Also, call the practice that sent you the letter, if there is a phone number on it.

Best of luck in resolving this!

Could be they are contracted with the hospital to attend to inpatients. Remember the good old days when your own doctor would make hospital rounds & oversee inpatient care? 😏

Hugs to you.

[cate94]

2. This doesn't sound legit

If it were me, I’d be calling Medicare.

[question everything]

4. And your member of Congress, even if a rabid R

Good luck for both of you.

[LoisB]

3. Healing thoughts for your husband. Never heard of Sound Physicians - sounds like some sort of

scam to me.https://soundphysicians.com/

[AnnaLee]

5. That is what I thought until I checked at CMS website

Last edited Wed Jun 22, 2022, 01:12 PM - Edit history (1)

That is where I found out that this experiment is actually in progress with intention to move all Medicare into some form of it in 2024. There was an Excel type data base of participants, BPCI_ADVANCED_PARTICIPANTS_MY5. I downloaded it and there are 38 entries sharing the same Tacoma, WA address that is on the letter. They seem to be hospitalists from several states (Ohio, VA, TX, CA, etc.) The last entry at this address is for Kansal Inc. (Legal Name), SOUND PHYSICIANS OF CALIFORNIA V (SBA name). No mention of my state, WA even though the home address is in my state.

So, this program does exist although I don't understand what it is or how (or if) my bills will get paid and transferred to my secondary payer like with Medicare. It almost sounds like a nationwide setup of HMOs. But honestly, I don't have the time or energy to track it down. I thought someone here might have already done my homework for me.

[LoisB]

6. I read through their website but can't get a handle on what they actually DO. There are many

generalities about "we help lower costs", "we help get better medical outcomes", "we partner with insurance companies & hospitals" but nothing about HOW they do any of this (at least not that I can understand).

[AnnaLee]

10. I couldn't figure it out either

What seems true is that "Sound Physicians" is a misnomer. The organization does not appear to be insurance or physicians but bureaucrats replacing Medicare and not answerable to anybody really including taxpayers.

[cbabe]

7. The Dark History of Medicare Privatization

https://prospect.org/health/dark-history-of-medicare-privatization/

The Dark History of Medicare Privatization

Medicare Advantage was supposed to be a money-saver. It’s now become a costly, unaccountable cash cow for private insurance companies that is swallowing traditional Medicare.

BY BARBARA CARESS JANUARY 24, 2022

Rep. Pramila Jayapal has called it the “biggest threat to Medicare you’ve never even heard of.” It’s known as Direct Contracting (DC), a program concocted by the Trump administration and not yet ended by the Biden administration to fully privatize Medicare.

DC is patterned after Medicare Advantage, the publicly financed, privately owned, hugely profitable version of Medicare now enrolling 26 million people at an annual cost of $343 billion. Simply put, DC is Medicare Advantage (MA) on steroids.

…more…

…

Rep. Jayapal, D-WA, chair of progressive caucus

[AnnaLee]

9. One MAJOR difference

You get to choose a Medicare Advantage Plan if you want one. You chose another option if you don't. It is not open season; however, CMS has let Sound take over my husband's Medicare without his knowledge much less his consent and while he is in the hospital. The letter, addressed only to him, came to my house. He is in assisted living when not in the hospital or nursing home and doesn't even reside here. He only knows about this because someone was here that could read mail addressed to him.

I just got back from the hospital. I asked him if he had signed anything or agreed to anything with anyone since he went to the ER. He said no but someone named David came to his room a couple of days ago wanting him to consent to something. He said he didn't, but he doesn't always tell the truth if he thinks he made a mistake. (He is in no condition to even comprehend what is said to him right now much less agree to it.) I think it was probably not these Sound people, but it just shows the stalking that seems to go on among sicker Medicare patients. Even legitimate business should not be conducted with a bedridden sick person.

I am going to see if I can opt-out on his behalf. I hope it is not too late for this current emergency. When he is discharged it will be to a nursing home rehab facility. What you want to bet I get a delinquent bill from Sound at some future time due to problems with properly getting my bill processed through Medicare then GEHA.

[cbabe]

11. Yes. Healthcare institutions, hospitals, medical

groups, phycians et al sign up and transfer to DC.

And all patients are automatically switched with no notice and no say.

So his doctor or hospital is in the DC system with him along for the ride.

Seems to me you might have a good legal argument being switched without consent and not able to give consent.

(Do you have power of attorney?)

Good luck and let us know how it goes.

[AnnaLee]

12. I have power of attorney

but I just pulled up the wording. It only kicks in if he is disabled or incapacitated. Does being in the hospital and too uncomfortable to care qualify? His brain works but he would likely say enough is enough and want to just not talk about it.

At CMS, the section of the 2018 document setting up the models for BPCI-Advanced targets people with already in progress "clinical episodes".
https://innovation.cms.gov/files/x/bpciadvanced-rfa.pdf
It might be that everyone getting this mail at home gets it when they are in the hospital and cannot receive it. If you pull the document, go down to page 6, and read under "Model Population" and the first couple of paragraphs of the next section, "BPCI Advanced Model Participation Agreement and Clinical Episode Selection", you will see why I think this.

[slightlv]

8. People are getting wise to the Medicare Advantage scams and are

opting out of them as fast as they can. I'm doing that as soon as I'm able this year. I got suckered in while in a covid mess with my Mom last year, while trying to take care of HER Medicare/Supplemental needs. Aetna took full advantage of my split attention. I detest them.

I swear, once you hit 65, you shouldn't HAVE to be dealing with insurance companies every year. You're already in decline in your brain cells, in general, and you hit your frustration point at a much faster level. It's a set-up ready-made to strip you of your money quickly and easily. It's abusive to the elderly and to caretakers, IMNSHO.

[AnnaLee]

13. Yes

Many times, in the last couple of years, I have gotten frustrated and angry at how much of the elder abuse comes from entities determined to make life as hard and complicated as they possibly can for the elderly. It is bad enough that crooks and some businesses try to scam the elderly. It is unforgivable that our governments (federal, state and local) join in by trying to turn our hard-earned benefits into a slush fund for their campaign doners. And "we the people" fall for the weasel words spit out as with this program.

The 2018 document for this BPCI Advantage program discusses that people can't opt-out because the idea won't fly if they are allowed a choice. And, if Biden doesn't do something soon, 2024 is the target year for a complete transition of Medicare to this model. I'm not sure what happens to Medicare Advantage. It might be left as is, who knows?