DCE For Clinicians
Is the ilumed DCE Right for Your Practice?
ilumed is a health care organization approved to participate in the Center for Medicare and Medicaid Services (“CMS”) Direct Contracting Entity program (“DCE”). ilumed was formed in 2018 by seasoned value-based care leadership, utilizing proprietary technology and establishing a network of leading providers with the mission of streamlining and modernizing healthcare. ilumed has participated in the DCE since the first implementation period in 2020 followed by the performance year one that started April 1st, 2021. We are your partner in managing value based quality standards and optimal clinical outcomes for your traditional CMS Fee For Service (“FFS”) beneficiaries.
What is a Direct Contracting Entity (DCE)?
The DCE Model is a new program from the Center for Medicare and Medicaid Services (CMS) that is intended to move Medicare Fee-For-Service (FFS) patients into value-based arrangements. This program builds on lessons learned from both the Accountable Care Organizations (ACOs) Model and Medicare Advantage Plans (MA). DCEs enter a value-based contract with CMS. Much like the ACO model, patients are automatically aligned to the DCE based on Primary Care claims. However, DCEs are like MA plans in that they are risk-bearing entities managing the care of a panel of patients.
Why is the DCE necessary?
With wide recognition of the unsustainability of US health care costs, the need to identify significant sources of savings has never been greater. It is no secret that the Medicare Fund (Part A) is already insolvent and is projected to have exhausted all reserves by 2026. With most ACOs unable to create significant savings, CMS has, through its Innovation Center, created new ways to move Medicare FFS patients into value-based models. As almost 2/3rds of all Medicare patients are not enrolled in a MA plan, this initiative represents a massive opportunity for entrepreneurial minded physicians.
The primary goal of the DCE is to create risk-sharing arrangements in the Medicare FFS landscape. The model is also intended to reduce the health care provider’s administrative burden, while empowering patients by giving them provider choices. There are a few key components to being successful in this value-based model: improving the quality of outcomes through proactive care, keeping patients in their best health at home, and avoiding crisis care. In other words: the right care at the right time and in the right place.
Why should you want to participate with ilumed?
If you are focused on improving quality and outcomes while reducing costs, growing your Medicare FFS market share, and earning shared surpluses created by improving patient outcomes, then you are already well-positioned for this new and unique opportunity created by Medicare in partnership with ilumed.
You may have treated Medicare FFS patients under other value-based models such as an ACO but may have faced attribution challenges or realized no shared savings. Unlike most ACOs and MA Plans, the ilumed DCE does not take a large percentage off the top for administrative costs. Therefore, we can share with our physician partners a larger percentage of the gains created from improved outcomes. This new risk-sharing arrangement gives you, as a DCE participant, the opportunity to realize Medicare savings created by appropriately aligning patients via claims, voluntary alignment, and reducing utilization as a result of providing quality care focused on patient engagement and improved outcomes. Partnering with ilumed may be a pivotal way to grow your Medicare FFS market share while participating in a proven risked-based contract model. ilumed will work with you to engage and support those Medicare FFS patients aligned with you as their PCP. This eliminates patient attribution challenges encountered in ACOs which often lead to the inability to achieve shared savings when patients are treated at out of network locations. With ilumed as your partner, you will have the opportunity to achieve gains from improved outcomes otherwise not seen in value-based payment models primarily driven via claims-based attribution.
ilumed will also work with you to identify high performing regional specialty providers and leverage the specialty network to deliver quality care to your Medicare FFS patients. We will work with your specialty providers to maintain engagement, and to help build relationships that meet the needs of the patient and the primary care providers.
Practices with a high level of Medicare FFS experience and a moderate to large Medicare FFS patient panel will find it beneficial to participate in ilumed’s capitated payment model which also includes a quality bonus and gains from cost-savings associated with improved outcomes. The capitated model provides consistent cash flow to the practice while supporting efforts to focus on patient engagement and personalized care in order to improve performance.
What does ilumed do for your patients?
Participants in the DCE model such as ilumed have been given the unique authorization from CMS to offer “Benefit Enhancements” that go above and beyond what is typically available to Medicare FFS patients. These extra benefits (e.g., targeted transportation), come at no cost to the patient. In partnership with your practice, ilumed will work as your patients’ advocate using an integrated “concierge” approach by removing potential barriers for better access to care.
A few examples of ilumed’s concierge services are: access to timely patient appointments, transition of care, appropriate home based care, centralized medical records, confirming your patients are seen by specialists assuring their consult notes are returned to you, the PCP, as the patient’s medical home.
Is your practice a good fit for the DCE model?
While the DCE model represents a significant opportunity, not every practice or organization is necessarily a good fit for the model. Here are some factors to consider when deciding if the model is right for you:
Does Size Matter? The smaller the panel of Medicare FFS patients, the more likely it is a few catastrophic patients could negatively impact your performance. However, becoming part of ilumed’s DCE insulates you from downside risk while you grow your panel. Understanding your current patient population and payer mix is important in determining the level of risk-share ideal for your practice in partnering with ilumed. Medicare FFS patients are allowed and encouraged to voluntarily align to your practice if they choose to build their provider relationship with your practice. By doing so, the opportunity for patient outreach and a higher level of patient engagement is created. Ilumed will assist your practice by reaching out to these patients on your behalf and encouraging them to engage with your practice in turn creating patient loyalty, retention, and panel size growth. As your panel size grows, so does the overall patient panel managed by ilumed; allowing ilumed to invest in enhanced patient benefits not historically available to Medicare FFS patients.
Attribution Do you practice episodic or reactive medicine only? Is it likely that you see patients that may not return? If so, then the DCE model is not right for you. A major pillar of the model is that you are responsible for the patients that are attributed to your panel. It is highly recommended that you see your Medicare FFS patients at least once quarterly. The model is designed so that if patients seek out primary care services outside of your practice it will result in loss of attribution. If you are unable to actively engage with your patients and manage your patients’ care, it is unlikely you will do well in this model. Ilumed’s outreach increases your ability to keep your patients engaged with your practice and eliminate “transactional medicine” thus improving patient outcomes.
Patient Engagement The physician-patient relationship is one of the most important facets of the DCE. Do your patients call you before going to the Emergency Room? Do they call you at home? Maintaining a good relationship with your patients ensures that the ball does not get dropped during acute events or transitions of care. It is important that you are the “Quarterback” of each of your patients’ care teams in creating your patient’s medical “home”. At its expense, Ilumed will conduct the necessary outreach to your patients to address their needs, support them and keep them engaged with your office, so you may provide them with continuously good care and eliminate “transactional medicine”. Having patients keep you “first” in their mind when they seek care helps lower costs over time and increases the opportunity to create gains from improved outcomes for your practice.
How is an ilumed DCE beneficiary different from a Medicare
Advantage Plan beneficiary?
Once a Medicare FFS beneficiary aligns to an ilumed PCP, the beneficiary becomes part of the ilumed DCE program. The ilumed beneficiary’s Medicare benefits will remain the same, they can visit any doctor, any hospital or any other health care professional. Additional benefits to an ilumed DCE beneficiary include access to the ilumed beneficiary care management team, and access to an ilumed beneficiary advocate to assist with care management needs.
Do ilumed beneficiaries have an I.D. Card to identify them as an ilumed beneficiary?
No, ilumed beneficiaries continue to use their Medicare benefit card.
What services are covered under ilumed?
All Medicare covered services.
What are the copays/coinsurance for ilumed beneficiaries?
Copays, Coinsurance and Deductibles apply as published by CMS. ilumed may offer reduced copays for PCP visits as an enhanced benefit to the ilumed beneficiary. We will provide a list of all ilumed beneficiary enhanced benefits to our PCP providers prior to January 1st of each year.
Do I need to get referrals to see an ilumed beneficiary?
No referrals required. ilumed beneficiaries are encouraged to follow their PCP’s guidance for care selection.
Do I need to get any authorizations?
Only for services not approved by CMS. Continue to obtain authorizations required from CMS.
Where do I send my claim for ilumed beneficiaries?
You still file your claims (and encounters) as you normally file to CMS.
Who sends our office the E.O.B. (or remittance advice) for services provided to an ilumed beneficiary?
You will still receive an E.O.B. (or remittance advice) from CMS.
Who pays me for services provided to an ilumed beneficiary?
Continue to submit your Medicare Fee For Service claims per your existing process. ilumed will remit payment pursuant to your contract with ilumed after your CMS claim adjudication.
What if I have claim payment questions?
Please contact your ilumed provider representative or email email@example.com and include your contact name, email address, phone number, provider name, TIN, NPI, physical address, billing address, Medicare number and details regarding the claim payment issue or question. An ilumed representative will respond to your inquiry.
How do I identify other ilumed participating providers?
Please click https://ilumed.com/dce-for-patients/dce-providers to review our participating provider roster.
What if I want to recommend another provider for participation in the ilumed network?
Please submit your provider nomination to firstname.lastname@example.org or contact an ilumed representative at 800.481.8745.
What if my patient wants to become an ilumed beneficiary?
Your patient can call 800.481.8745 or email email@example.com to reach an ilumed representative. Additionally, your patient can confirm their PCP selection here: https://ilumed.com/dce-for-patients/dce-confirmation-form/
If you identify with these patient care philosophies, are interested in learning more about ilumed’s DCE model and would like to participate in this great new opportunity, ilumed will gladly assist in reviewing the ilumed partnership risk-sharing options in this value-based model. You can reach us by calling 877-4ilumed (445-8633) or emailing us at firstname.lastname@example.org. We welcome all inquiries as we create a broad and diverse provider network.