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Ed Gaines

@EdGainesIII

Mar 21

1/Great to hear and I'll be happy to share "1st principles" for TPAs but unfortunately cannot share contracts, those are proprietary to clients & they pay for our expertise there. To the community, let's provide your suggestions here or separately to Mr. Cuban recognizing that most of us including me have day jobs...so let's get started.

2/A couple of charts to begin the discussion. @FAIRHealth is a non-profit database of health plan allowed amounts w/ >50B in charges & allowed amounts. It was created as a result of the class action settlements vs. @UHC & other health plans regarding the "Ingenix database" over a decade ago. The #NoSurprisesAct was effective as 1/1/22, banned out of network (OON) balance billing & established an independent dispute resolution (IDR) process for clinicians to resolve their OON reimbursements. This chart is for an ~4.5 yr. period, both pre-NSA & post-NSA. Clinician charges either remained static or increased during this period. In network allowed amount declined -14% & OON allowed amount declined ~-10%. This naturally caused clinicians to enter the NSA IDR process in response. Articles on health plans "weaponizing" the NSA are plentiful, including @BlueCrossNC @BCBSTN @Cigna.

3/ Here are 2 of more than several examples of health plans "weaponizing" the #NSA. So among the "1st principles" is "Do not weaponize the NSA". A few more charts will describe why. Also note that a federal district court in Tyler, TX known as "The TMA cases" in 4 separate lawsuits has struck down NSA rule making by 3 depts. of the federal administration. HHS, DOL & Treasury were found to attempt to create an unlevel playing field where Congress intended the playing field to be fair. Despite an unlevel playing field in '23, CMS' own data (see the link to the CMS report below) shows that clinicians won 77% of IDRs vs. health plans in Q1 & Q2 '23.

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Ed Gaines

@EdGainesIII

Nov 29, 2023

1/ From #RSNA2023 presentation by @reh3md, the issue is well captured by this @AmerMedicalAssn graph showing that physicians are the only ones that do not receive an CMS $ update of some kind (may not be full inflation) but hospitals, ASCs, SNFs et al receive positive updates:

2/ Dr. Heller's next slide is specific to #Radiology #RVUs & the #Medicare negative update above would be added to the RVU cuts. The bottom line as he said @RSNA2023 is that the best that Radiology has done is "0%" in the past 15 yrs. RVU impacts on other specialties vary.

3/ The answer to the lack of #Medicare updates for physicians writ large is advocacy & docs being active in the national, state & local specialty organizations. @ZotecPartners we have what we call "1 click" advocacy where it takes less than 1 min. to send an email--check it out

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Ed Gaines

@EdGainesIII

Feb 22, 2023

1/ What’s the urgency re: #NoSurprisesAct dispute resolutions decisions (IDRs) returning immediately you ask? 1st, amicus briefs are important but they’re but 1 tool in the tool box. “We” need to do more, to wit: for EM docs the decline in post #NSA reimbursements is >32% so….

@EDPMA

2/ IDR is the main remedy to the EM Docs who have (willingly) the #EMTALA & moral duty to provide care regardless of the in network status; 2. @EDPMA survey data on the +30% decline in pre vs post NSA reimbursements is 10s of 1000s of claims. 2 paraphrase the movie “Patton”, how

@ACEPNow

3/will we all answer the question “where were you & what do you do when independent physician groups’ independence suffered an accelerate decline?” To borrow a line from Netflix doc “Full Swing” (attributed to Tiger) “ Don’t get bitter, get better” @ACEPNow @ACRRAN @ASALifeline

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Ed Gaines

@EdGainesIII

Oct 20, 2022

1/Big congrats 2 the Physicians Advocacy Institute, American College of Emergency Physicians, American College of Radiology, American Society of Anesthesiologists, American Hospital Association, American Medical Association, and The Emergency Department Practice Management....

@EPDMA

2/ Association for filing w/in a very short timeline (@EPDMA found out last Friday that 10/19/22 was the deadline for amicus briefs--FUN weekend!) "friends of the court" (amicus curiae) briefs in support of @texmed @AdamCorley Motions for Summary Judgment to have the Aug. 2022...

@AmerMedicalAssn

3/ NSA final rule vacated, just as the court had previously ruled in Feb. 2022 with the Q4 2021 final rule--with @AmerMedicalAssn PAI coming in with over 30 state & federal medical societies joining to oppose yet another ill fated attempt by HHS to set the QPA as a benchmark....

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Ed Gaines

@EdGainesIII

Sep 14, 2022

1/ Here's a call to action for the bill to address the Medicare fee schedule cuts--Tell Congress: Fix Medicare Reimbursement!
Clinicians are working harder than ever to recover from the pandemic—but continually facing cut after cut, and inflation is on the rise......

2/Insurers, who posted record-breaking pandemic profits, continue to raise premiums and lower reimbursement rates to clinicians. Additionally, across-the-board, sequestration cuts of -2%, just hit our clinicians in the first half of 2022.
January 1, 2023, approximately.....

3/ -10% plus, in Medicare cuts will impact hospital-based clinicians. We need Congress to enact new legislation to STOP THE CUTS!
•-4.42% - Medicare conversion factor (CF) cuts were proposed by CMS’ 2023 Medicare Physician Fee Schedule (MPFS).
•-4% - Pay-As-You-Go (PAYGO) ...

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Ed Gaines

@EdGainesIII

Sep 14, 2022

1/ Good news on CMS fee schedule--Reps. Ami Bera (D-CA) and Larry Bucshon (R-IN) introduced legislation Tuesday (Sept. 13) to mitigate CMS’ proposed physician fee schedule cuts for 2023, which doctors have decried since the rule was released, by increasing the conversion .....

2/ factor 4.42%effectively putting the cuts on hold for a year. Congress has stepped in the past few years to help mitigate physician fee schedule cuts, and stakeholders have urged lawmakers to do so again prior to 2023. The lawmakers, who recently spearheaded .....

3/ a bipartisan request for feedback on how to revamp the flawed Medicare Access and CHIP Reauthorization Act, also include in their newly introduced Supporting Medicare Providers Act a sense of Congress that HHS, the House and Senate should administratively and legislatively ...

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