@ZachJonesForTX @mass_marion 1/ Zach--where do I begin? 1. For those thinking that the #NoSurprisesAct is about out of network (OON)/balance billing (BB)--maybe 3-6% of a hospital based group--sorry--it's all about in network rates; the vaulted @USCBOcostest calculated that the Energy & Commerce bill in '19.
@ZachJonesForTX @mass_marion @USCBOcostest 2/ would "save" ~$20B over 10 yrs. BUT 80% of that savings would come from the declination in network rates; my opinion you say? Actually no--last week @BlueCrossNC wrote to over 50 physician groups in #NC citing the NSA and NC state law--groups in Rad., Anesthesia & EM--and....
@ZachJonesForTX @mass_marion @USCBOcostest @BlueCrossNC 3/ demanded (and we have letters to support the same) between -5% to -20% in current participation agreements (cuts rumored to be as high as -30%) else #BCBSNC would consider terminating the agreement b/c the #NSA & the #QPA as calculated would permit "interim reductions".....
@ZachJonesForTX @mass_marion @USCBOcostest @BlueCrossNC for "outlier contracts" w/ a demand that was by 12/15/21--I am frankly done w/ them & it's time to take off the gloves--30 yrs I have battled w/ this plan & friends it is high time to call total BS on their current tactics--give no quarter--@BlueCrossNC & its ilk have minted $...
@ZachJonesForTX @mass_marion @USCBOcostest @BlueCrossNC 5/ (I am so pissed off I did not number #4 above) while you all have been on the wall for us dying and saving lives--I will be damned if they get to drive physicians & hospitals to the brink on my watch and do nothing--here are the letters--make sure you have a beverage of choice
@ZachJonesForTX @mass_marion @USCBOcostest @BlueCrossNC 8/ PS--when I first received this letter last week, I thought it was a fake--sadly it is not--a large physician group practice manager called the 15+ yr VP of BCBSNC to ask if he really sent it--he said that he did--reportedly over 50 groups in NC received it. @drdanchoi

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More from @EdGainesIII

13 Nov
1/ As famous @WakeForest professor Maya Angelou said, “When people show you who they are believe them” —stunning reveals here—Former @UHC exec says company would only pay surprise bills after complaints….beckershospitalreview.com/payer-issues/f…? @drdanchoi utm_source=twitter&utm_medium=social
3/ So the former senior exec. for @UHC admits that it did not inform members in writing via letter that #UnitedHealth would reimburse out of network bills, instead it was buried in the fine print of the #EOB to the Pt. & Pts. had to ask UHC to pay.
Read 4 tweets
30 Sep
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".
Read 7 tweets
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

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