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Ed Gaines

@EdGainesIII

Feb 28

@texmed

1/ Great potential news on the #NSA @texmed & @AdamCorley lawsuit response from @CMSGov --quoting--"The Departments are reviewing the court’s decision and considering next steps. This announcement serves as a notification to health care providers, emergency facilities....

2/ "providers of air ambulance services, group health plans, health insurance issuers, Federal Employees Health Benefits (FEHB) Carriers (“Disputing Parties”), and certified IDR entities of steps the Departments are taking to conform to the court’s order. Specifically, the ....

3/ Departments will:
1.Effective immediately, withdraw guidance documents that are based on, or that refer to, the portions of the Rule that the court invalidated. Once these documents have been updated to conform with the court’s order, we will promptly repost the updated....

Read 11 tweets

Ed Gaines

@EdGainesIII

Nov 22, 2021

@ZachJonesForTX

@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

@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

@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".....

Read 11 tweets

Ed Gaines

@EdGainesIII

Nov 13, 2021

@WakeForest

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

@Reese_Tassey

2/ @Reese_Tassey @813JAFERD @sonodoc99 @fuzzymittens @amychomd @ercoderguy @MarilynHeineMD @Valleus556 @mass_marion @A4Horg @CRCook1978 @ZachJonesForTX @ASAGrassroots @EmergencyDocs @RadiologyACR @AmerMedicalAssn @ahahospitals @teamhealth @EDPMA @KatieOrrico @GrassrootsEM

@UHC

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

Ed Gaines

@EdGainesIII

Sep 30, 2021

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 .....

@CMSGov

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

Ed Gaines

@EdGainesIII

Sep 15, 2021

@UHC

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 ..

@drdanchoi

3/ home to roost as we in #NC. What say we #Medtwitter? @drdanchoi @813JAFERD @ercoderguy @amychomd @Valleus556 @sonodoc99 @JenniTelesz @purviparikhmd @SunnyJhaMD @Reese_Tassey @mass_marion @MarilynHeineMD @KatieOrrico @fuzzymittens @ERGoddessMD @TakeWeightOffMD @DrAlexUrology

Read 4 tweets

Ed Gaines

@EdGainesIII

May 25, 2021

@AHIPCoverage

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!

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