Ed Gaines Profile picture
Jul 20 9 tweets 9 min read
1/ Folks, @UHC must be called out w/ official complaints to the NSA CMS complaint portal as they have created an artificial, illegal & unnecessary process to try to "burn the clock" on physician's rights under the #NSA. To wit here's what they direct physicians to do, bare w/...
2/ me--from #UHC website: “How to submit an open negotiation request by email or mail section.”
Reminder: If you submit a negotiation request through that portal, you will not need to complete either the Open Negotiation Notice Form or the Supplemental Open Negotiation....
3/ Request Form." And here are the @UHC forms--they are creating an illegal "acceptance process" when CMS has promulgated exactly 1 form for the official 30-day Open Negotiation Period notice; and unlike other CMS forms, it's not suggested--they want...
uhcprovider.com/content/dam/pr…
4/ the official CMS form used (see link below); folks you have exactly 30 business days to file the CMS Open Negotiation period notice from the initial payment or denial--#UHC knows this & yet they require a log-in & password + UHC states that both the CMS form & their form....
5/ must be completed FOR EACH DISPUTED CLAIM--WRONG! UHC is attempting to "run out the clock" (ala Dean Smith's famous 4 corners, apologies to my Tarheel friends 2 mention the HOF coach in the same sentence w/ UHC) so that physicians 30 business days run out on the claims--how..
6/ so--we know this when you look at the form & it asks you to select "create claim reconsideration" & then to submit a reconsideration--folks that's a claim appeal & that is not the federally mandated 30-day open negotiation period notice! While they are sitting on the appeal...
7/ your 30 business day period just expired & those claims are no longer eligible for IDR--UHC is completely out of control & @CMSGov has to intervene--while @UHC continues to post record $Bs in profits each quarter--earnings up 19% YOY--this is an outrage & a new low even for...
8/ them & that is really saying something. Time every specialty & healthcare organization file complaints--here's the link cms.gov/nosurprises/po… and here is the only official 30 day open negotiation period notice & THERE IS LEGALLY NO ACCEPTANCE PROCESS
dol.gov/sites/dolgov/f…

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More from @EdGainesIII

Jul 15
1/Let’s be very clear about @UHC —for nearly 10 yrs I have chaired @ACEPNow Reimbursement Committee Work Group 2 charged w/ monitoring & addressing “bad payor” issues; for the,past +5 yrs nearly every month #UHC final diag. lists that down-pay/down-code….beckerspayer.com/payer/team-hea…
2/ blatant violations of federal & state prudent lay person laws w/ their Medicaid plans, non-compliant coding policies vs. AMA CPT stds. (Standards mandated by HIPAA regs.) & now policies set for 8/1/22 requiring FAXED medical records for E&M service w/ the -25 modifier…..
3/So these @UHC policies do not differentiate in ownership models, e.g. small, medium & large groups—the policies impact all EM docs while as just noted #UHC posts yr after yr record profits & revenue >; robust debate about group structures—sure but let’s not turn that into a ….
Read 5 tweets
Jun 6
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".
Read 7 tweets
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

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