Ed Gaines Profile picture
Jun 6 7 tweets 8 min read
1/ Important #NSA update as @CMSGov has posted "a checklist of reqs. for group health plans" after rec'g @ACEPNow @EDPMA letters & examples detailing numerous instances of #healthplan non-compliance w/ regs; 2/ The agency details several of most impactful non-compliance issues...
2/ health plans requiring that physicians/hospitals proceed through hosted website by the carrier to initiate the req. 30 day open negotiation period + lack of QPA info. + lack of health plan name, address AND email for sending the open negotiation notice 3/CMS states clearly....
3/ that the initial payment should be an amount the health plan "reasonably intends to be payment in full) (p. 2); 4/ CMS makes clear that the "clock" for the 30 day open negotiation period notice begins to run upon sending the notice, not per an "acceptance process or website".
4/ health plans must provide contact information including an email address (emphasis in the original) + that if the plan requires a website that the 30 day clock runs from the date the notice is emailed "regardless whether the non-initiating party "accepts" the notice or not....
5/ Even if the health plan declines 2 accept the 30 open negotiation period notice but the initiating party sent it to a proper email address then the 30 day clock has begun; 6/ details on the QPA which are reiterated from the regs. are also emphasized again. @ASALifeline .....
7/ cms.gov/files/document… 2 of the 4 pages below--advocacy can =tiring/frustratingly slow & sometimes appear that the stakeholders are not making progress--this ladies & gentleman is the result in part of #ACEP & #EDPMA members who have worked together weekly for nearly 2 yrs!

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More from @EdGainesIII

Apr 1
1/ Ironic that in the latest "shake-down" of #NC physicians @BlueCrossNC starts out by saying that they are a "non-profit" seeking to drive down "the costs of delivering healthcare." Let's look at their CEO comp. in '20--$3.14M + 8 of their execs. received at least $1.33M in.....
2/ compensation in '19; you may remember back in Nov. '21, citing to the #NoSurprisesAct, #NCBlue demanded that 54 hospital based groups immediately agree to contract rate reductions in the range of -5% to -30% or face contract termination--thought the letter was "fake news".....
3/ and it wasn't as an NC practice manager who knew the BCBSNC VP who signed the letter called him & said "is this for real?" Yes it was, said the VP; anyway the latest iteration of @BlueCrossNC w/ 60-70% of the commercial market using it's oligopoly power is cited below; for....
Read 6 tweets
Feb 28
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
Nov 22, 2021
@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".....
Read 11 tweets
Nov 13, 2021
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
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 .....
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
Sep 15, 2021
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

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