1/ CMS has done exactly what Congress refused to do--Congress rejected several "benchmarking bills" (setting physician reimbursement at a determined std.) in 2019 for out of network (OON)/balance billing (BB) & passed the #NSA which expressly avoided "rate setting", now in .....
2/ federal rule making @CMSGov has said that the "qualifying payment amount" (QPA) (median in network rate for same/similar services for same specialty in an MSA as of 1/31/2019) is the "presump[tive] appropriate OON amount"--not 1 of several factors to be used as Congress said..
3/ physicians may bring in other factors (thx CMS, Congress specified that they could in statute) if the information is "credible" + the physician must "clearly demonstrate" that the value of the service is materially different from the QPA & that the adjudicator "must consider".
4/ the physician's information. So CMS took a statute that listed several factors (not weighting any factor more than the other)--qualifications of the physician + complexity of the case + prior contract rates for 4 years + market concentration + quality & outcomes--& made it ..
5/ into a benchmarking law which Congress rejected in 2019 in the E&C bill and the Pallone/Alexander compromise--time for Congress to tell CMS that was not their express intent. @amychomd @drdanchoi @813JAFERD @ercoderguy @Reese_Tassey @sonodoc99 @wilfordgibsom @KatieOrrico ...

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More from @EdGainesIII

15 Sep
1/ Lookie here: CMS blocks 3 UnitedHealthcare Medicare Advantage plans from 6 states--for failing to meet their mandated "medical loss ratios" (MLRs) where they're supposed to spend 85% of the premium dollar on health care between '18-'20 yet @UHC says.. beckershospitalreview.com/payer-issues/c…
2/ "COVID-19" was the reason that they didn't make their MLR requirements--really? How was COVID-19 a factor in '18 & '19? Folks didn't defer care then for COVID-19 w/ first reported US cases in December--so what's your new excuse--give us one that we believe--chickens coming ..
Read 4 tweets
25 May
1/ In what has 2 be described as a stunning “admission against interest” (lawyer term for someone who speaks against their own interest & is deemed to be highly probative of the truth in evidence), the #TX @AHIPCoverage speaker presented a slide of ED pro fee charges & payments..
2/ slide shows that for 5 levels of ED pro fee claims the initial payments average was $142–database of >76K IDR disputes—& the adjudicator’s average award (all 5 ED levels averaged) was $985, that’s 6.94X of the health plan’s initial payment—improved from first 10 months—so …..
3/ what does this say about IDR as the method to resolve $ disputes? 1. Health plans ridiculously low ball initial payments; 2. Physicians are winning more now 16 months in vs. the first 10 months; 3. The average award has increased to nearly 7X from 4.5X initially; 4. Booyah TX!
Read 5 tweets
21 Apr
@HLPI_UHLC 1/ Frankly surprised at this article’s lack of substance beyond the basics—not to mention several of their statements which are either unsupported by data or experience.
1.Authors claim that the NSA will likely have little impact on physicians who do not engage in SMB....
@HLPI_UHLC 2/ —that’s not what the CBO thinks per their scoring of the E&C bill;

2.Outside of the biased studies out of Georgetown by the policy institute funded by the founder of Wellpoint health plan, there is not objective data that either the NY or NJ SMB models are inflationary.....
@HLPI_UHLC 3/ in fact, the NY DFS noted in their report in 2019 that folks there have saved over $400M—how is that inflationary?

3.Authors clearly like the CA model of benchmarking with no reference at all to the surveys done by the CA medical association of its members......
Read 4 tweets
21 Dec 20
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....
Read 11 tweets
11 Dec 20
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 20
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

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