1/ In the "section by section" summary, several key #SMB changes from the 12/11/20 draft appear to have been made (subject to seeing leg. language): 1. the median in network rate must be "market based" instead of unilaterally determined by the health plan (++); 2. gov't payors...
2/ "public payor rates" cannot be considered by the adjudicator, & not charges (that was in the earlier draft); 3. Not sure if the tech. issues w/ claims that occur during the IDR being eligible for the next IDR were addressed--seems like they're trying to there; 4. stay tuned
3/ "trying to get there"... if I had a nickel for every typo in the past month....
4/ The bottom line--this bill--subject to seeing the actual language--is WAY better than the E&C bill in the Spring of '19 & later the Pallone/Alexander compromise--so all you advocates out there--maybe you doubted "that 1 doctor could make a difference"--feel good that u did!!!
5/ more positive changes we’ve sought—5. Changed that the health plan had to “respond” (12/11/20 version) to a claim for payment to that they have to make an “initial payment or notice of denial” (state prompt pay laws would help here but ERISA plans might claim exemption) ....
6/ the “2 calendar day notice” period 4 physicians has been > to 4 days, better but not optimum—more later—new bill adds >100 pages to a nearly 400 page bill. So #SMB is plus 500 pages & the total Omnibus has be well in excess of 2-3K pages—maybe 4-5k? And members will know it?
7/ More potential good news as we delve into the bill--and 2021 rule makine will be critical--the Sec. of HHS will have discretion to modify both deadlines & timing requirements re: the 90 day colling off period, e.g. for small group practices, & that all claims pre....
8/ IDR decision are permitted into the next IDR after the 90 day cooling off period (note the typo above uugghgg) as follows:
1.‘(9) WAIVER AUTHORITY.—The Secretary may
2.10 modify any deadline or other timing requirement
3.11 specified under ......
9/ this subsection (other than the es-
4.12 tablishment date for the IDR process under para-
5.13 graph (2)(A) and other than under paragraph (6))
6.14 in cases of extenuating circumstances, as specified
7.15 by the Secretary, or to ensure that all claims that ....
10/ 8.16 occur during a 90-day period described in paragraph 17 (5)(E)(ii), but with respect to which a notification is 18 not permitted by reason of such paragraph to be 19 submitted under paragraph (1)(B) during such period, are eligible for the IDR process.’’.
*rule making*

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More from @EdGainesIII

11 Dec
1/ Ranking Minority Brady is supposedly meeting w/ W&M chair Neal in the am as a "Grand Bargain" is perhaps coming together after pressure from @SpeakerPelosi on #SMB--w/ no legislative language socialized 2 anyone in the doc community--2 of 4 corners in Senate remain opposed.
2/ Let's bolster the oppo w/ the simple message that we don't sign off on deals where there's no language + how about the bills that physicians passed in #NY #TX & #GA tens of millions of Pts are out of the middle due to physician lead bills--don't suggest "we're the party of no"
Read 7 tweets
1 Dec
1/ New #SMB data from #TX @TexasTDI --great & timely report--hot read as follows, data from 1/1/20 to 10/31/20--a. 32,036 IDRs filed, 86% from @EmergencyDocs, 7% anesthesia & 5% other specialties; b. Settlements (after IDR is filed)--clinicians are receiving +4.43X of the ....
2/ initial health plan reimbursement; c. when the adjudicator decides the IDR, clinicians are receiving 4.74X of the initial reimbursement from the health plan. The latter figure has come down from 5.3X when the IDR is adjudicated based on the first 6 month's report.......
3/ #TX model is working while not perfect for either side--costs for IDR are split and not loser pays but no law is perfect--TX continues to get an "A" @Reese_Tassey @drdanchoi @sonodoc99 @ercoderguy @amychomd @fuzzymittens @mass_marion @Valleus556 @TexACEP @szaafran ImageImage
Read 4 tweets
9 Nov
@sonodoc99 @mssnytweet @CNBC 2/ @pfizer CEO on @CNBC said that they have 50M doses ready for ‘20 & 1.3B doses scheduled for ‘21 + no negative implications were reported yet the firm does not have visibility into the panel’s specific data set + Pt cohort ranges from 84 to 12 yrs. old....
@sonodoc99 @mssnytweet @CNBC @pfizer 3/ big thx to @BeckyQuick for expressing the emotions of tens of millions of your fellow citizens—the biggest & best news of the year!
@sonodoc99 @mssnytweet @CNBC @pfizer @BeckyQuick 4/ @pfizer CEO says that the @US_FDA will review the detailed safety data next week + he received the phase 3 results Sunday Nov. 8th about 2pm
Read 5 tweets
24 Sep
1/ POTUS Executive Order (EO) is potentially back on & here’s the outline on the terms & conditions—the EO has been drafted—whether he announces it in the Queen's City today & that he’ll sign it is another open issue: #medtwitter
1. The prohibition on surprise medical billing...
2/ will be linked to the hospital’s conditions of participation (CoPs);
2. By law, physicians do not have CoPs—hospitals have them—so this may be an immediate potential legal argument against his actions;
3. The EO would pit hospitals against the physicians credentialed....
3/ at the hospital;
4. The concept is “network matching” & was raised during the E&C committee hearings and rejected by the committee as a solution—require that every physician group credentialed by the hospital “match” the hospital’s network of health plans;
5. The hospitals
Read 5 tweets
22 Sep
1/ As reported in PoliticoPro –
Trump preparing executive orders on health care this week
By Susannah Luthi, Daniel Lippman, Dan Diamond
09/22/2020 02:51 PM EDT
President Donald Trump is planning to announce a series of executive actions on health care as soon as Thursday...
2/ & one EO is expected to be on #surprisemedicalbilling --been rumored for months & details are not known--last WH idea was outright ban on OON/BB w/ no mechanism for physicians & health plans to resolve $ disputes but Pts would be protected--WH COS Meadows was against ....
3/ benchmarking when he represented Asheville NC in the US House--legal authority of POTUS here very questionable as it relates specifically (but not limited to) to ACA and ERISA plans as those have specific Congressional statutes authorizing same--physicians have been approached
Read 5 tweets
17 Sep
1/ So the #TX health plans--after supporting the solution to #surprisemedicalbilling which passed unanimously--are now pointing fingers--lets consider the facts--1. per the TX Dept. of Insurance (TDI), when clinicians informally settle their dispute before the formal dispute ....
2/ resolution process (IDR), the plans are settling for 4X of the original reimbursement paid; when clinicians go thru the IDR process, the independent dispute adjudicator is awarding >5.3X of the plan's initial reimbursement--based on TDI's report of the 1st 6 months--see charts
3/ So the original plan reimbursements are unreasonably low--one could reasonably conclude--so low that the plans are willing to pay 4X in settlement before IDR--& the Pts are protected & removed from the IDR process--the statutory factors for determining the final $ are strong ImageImage
Read 6 tweets

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