Clover Health aims to drive physician acceptance of its software by paying Medicare Advantage enrollees to visit providers that have agreed to adopt the Clover Assistant tool next year.
Insurtech will offer Medicare Advantage members $150 when they book in-person, virtual, or in-home visits with providers using Clover Assistant. The company, which has 88,000 Medicare Advantage customers, describes Clover Assistant as an electronic medical record combined with an artificial intelligence engine that prompts doctors for diagnoses, codes, and care procedures.
The company announced the plan last month when it announced Medicare Advantage services for 2023. Clover Health paid providers $200 for each visit they used Clover Assistant to catalog conditions patient’s condition.
“It’s important to equip doctors with technology just to help them make better decisions without forcing them to do anything they don’t want to. Clover Assistant was born from that insight,” Clover Health President Andrew Toy said during the company’s third-quarter earnings call on Monday.
Toy will become CEO on January 1. Clover Health declined to comment for this article.
Clover Health has built its business around Clover Assistant.
Insurtech attracts Medicare Advantage members with its extensive network and generous benefits, and introduces its Clover Assistant technology to be able to manage their care and reduce costs. The company thinks its user-friendly software will appeal to doctors. “We believe our Clover Assistant-powered model gives us a structural advantage over other industry participants, enabling profitable growth in the market,” said Toy.
Clover Health’s net loss increased 118% to $75.3 million in the third quarter on revenue of $856.8 million.
Not every provider contracted with Clover Health uses their software. The company stopped short of disclosing how many doctors joined earlier this year because it said members switching between Medicare Advantage and its Direct Contract organization made the numbers impossible to compare quarter-to-quarter. The Centers for Medicare and Medicaid Services redesigned the Direct Contract billing model into a Responsible Care Organization REACH program for 2023.
The adoption and use of Clover Assistant by vendors has been the subject of constant speculation.
Ahead of Clover Health’s special-purpose acquisition in January 2021, Gary Taylor, managing director and senior equity research analyst at Cowen, called a “small” number of providers. in the Clover Health network, none of them told him they used Clover Assistant, he said. . Taylor cites accounts from doctors who have reported that using a new tool is not worthwhile for the small number of Clover Health policy holders they treat. Some doctors will enter their patient information into the system after a visit just to earn a bonus. , Taylor said.
“If a patient goes to see a doctor with that view, then you won’t benefit from the model,” Taylor said. “So now you have to pay this extra cost to try to direct patients to doctors who are actually using the software. All are this kind of circular, the thesis failed. ”
A Hindenburg Research report published last year also found similar findings. Dozens of doctors have told the investment research firm that Clover Assistant is difficult to use.
The same report revealed that the Justice Department is investigating Clover Health for allegedly overpaying to Medicare. Hindenburg Research also quoted doctors as saying the Clover Assistant is a tool for Medicare Advantage risk-modifying gaming, which will pay providers more if they manage patient care. heavier. Some Medicare Advantage insurers are accused of exaggerating a member’s illness to generate more revenue.
Clover Health has said the Justice Department investigation is routine for the industry and it disagrees with the Hindenburg Study report.
Health insurers have long pushed providers to adopt their preferred software systems. But Clover Health paying patients to visit providers using its technology “seems scary to me,” said Aaron Miri, co-chair of the federal Health Information Technology Advisory Committee, an expert panel that advises the federal government on health IT policy. Insurtech may have to pay patients to choose which providers to use their software to avoid violating patient guidance laws, he said.
“If there was money, UnitedHealth, Blue Cross, they would all do the same thing. This seems like something too good to be true. I would be very, very cautious,” said Miri, who is also senior vice president and chief digital officer of Baptist Health South Florida in Jacksonville. “That sounds like an unsustainable funding mechanism.”
The only way to pay patients to visit specific providers, Miri says, that can make economic sense is through the Medicare General Savings Program, a payment model that rewards doctors who meet certain criteria. care and quality index.
Clover Health is not currently participating in the Medicare General Savings Program, but will increase its participation in the ACO in 2023, the executive said Monday. The company plans to reduce participation next year in Direct Contracts, now ACO REACH, and move physician partners to the Joint Savings Program.
There are technical differences between the two models, but the main difference is how providers are rewarded. Under ACO REACH, participants can be penalized during their first year for exceeding the cost of care for an individual patient, meaning they have to accept low risk. With the Medicare General Savings Program, eligible doctors can only accept increased risk for up to seven years, meaning they can only make money during that time.
“We have a lot [ACO REACH] applicants and they can transfer to a single assistance program such as the Medicare General Savings Program, move through the different stages of the Medicare General Savings Program and then, when appropriate, graduate into a programs like the ACO REACH program,” said Clover Health CEO Vivek Garipalli during the third-quarter earnings call.
“We think that’s closer to what CMS envisions,” says Garipalli.
Clover Health may collect referral bonuses for referring patients to providers’ Medicare Shared Savings Programs, Ms. Miri said. Health systems could also contract with Clover Health to help run the payment model for referred patients and split them a portion of the Medicare payout bonus, he said.
“If they direct you to a particular ACO in a health system and they cut deals with the health system, then the health system cuts that percentage because you increase your insured life. them,” said Miri. “That’s where they have to make money from.”
