“Carve-ins” are benefits offered to your patients the cost of which are included in your capitation.
If you’re financially risk-sharing, that means part of the costs of those carve-ins are are coming out of your pocket.
Yet you have no control over how much you pay for those benefits, your Medicare Advantage insurance partner does. And they have many other objectives other than maximizing the value of the contract they share with you.
As new “carve-ins” are added under your contract, compare the payment rate with the standard Medicare rate for those services.
Can’t get the insurer to tell you the contracted rate (which in itself if a red flag?). Figure it out yourself with your own data.
If there is a discrepancy, your insurer may be horse-trading with that vendor—and passing along the costs to you while sharing none of the benefits.
It happened to us and we called our insurance partner on it.
They were surprised we figured it out, and they only made changes because of our position in the market.
It’s key to realize that, under Medicare Advantage, you as a risk-sharing clinician or provider is essentially becoming an insurance company—one with less control over costs than you should.
This is an unfamiliar role for most of us and it requires being vigilant, pro-active, and assertive.
Or you’re going to lose your shirt and not realized it until the moment it comes off your back.