Ed Gaines Profile picture
#healthcare #attorney #physicians & #clinicians advocate, honorary member of #ACEP & co-founder #EDPMA, #tennis enthusiast & dad—posting as an individual
Feb 22 4 tweets 4 min read
1/ What’s the urgency re: #NoSurprisesAct dispute resolutions decisions (IDRs) returning immediately you ask? 1st, amicus briefs are important but they’re but 1 tool in the tool box. “We” need to do more, to wit: for EM docs the decline in post #NSA reimbursements is >32% so…. 2/ IDR is the main remedy to the EM Docs who have (willingly) the #EMTALA & moral duty to provide care regardless of the in network status; 2. @EDPMA survey data on the +30% decline in pre vs post NSA reimbursements is 10s of 1000s of claims. 2 paraphrase the movie “Patton”, how
Oct 20, 2022 4 tweets 6 min read
1/Big congrats 2 the Physicians Advocacy Institute, American College of Emergency Physicians, American College of Radiology, American Society of Anesthesiologists, American Hospital Association, American Medical Association, and The Emergency Department Practice Management.... 2/ Association for filing w/in a very short timeline (@EPDMA found out last Friday that 10/19/22 was the deadline for amicus briefs--FUN weekend!) "friends of the court" (amicus curiae) briefs in support of @texmed @AdamCorley Motions for Summary Judgment to have the Aug. 2022...
Sep 14, 2022 4 tweets 1 min read
1/ Here's a call to action for the bill to address the Medicare fee schedule cuts--Tell Congress: Fix Medicare Reimbursement!
Clinicians are working harder than ever to recover from the pandemic—but continually facing cut after cut, and inflation is on the rise...... 2/Insurers, who posted record-breaking pandemic profits, continue to raise premiums and lower reimbursement rates to clinicians. Additionally, across-the-board, sequestration cuts of -2%, just hit our clinicians in the first half of 2022.
January 1, 2023, approximately.....
Sep 14, 2022 4 tweets 1 min read
1/ Good news on CMS fee schedule--Reps. Ami Bera (D-CA) and Larry Bucshon (R-IN) introduced legislation Tuesday (Sept. 13) to mitigate CMS’ proposed physician fee schedule cuts for 2023, which doctors have decried since the rule was released, by increasing the conversion ..... 2/ factor 4.42%effectively putting the cuts on hold for a year. Congress has stepped in the past few years to help mitigate physician fee schedule cuts, and stakeholders have urged lawmakers to do so again prior to 2023. The lawmakers, who recently spearheaded .....
Aug 20, 2022 10 tweets 5 min read
1/ Random musings on the #NoSurprisesAct final rule issued 8/19/22--sorry for the trade speak in advance but otherwise this string would be 50+--the "qualifying payment amount" serves 2 purposes--determine Pt cost sharing & as a factor in IDR; QPA by definition repeated in the... 2/ rule is the median allowed amount determined by health plans for same or similar svs. as of 1/1/19--adjusted for inflation; now my doc friend who used to be an actuary says the CPI on the QPA should be +20%--then how would over 90% of the claims surveyed by @ACEPNow & @EDPMA..
Jul 26, 2022 7 tweets 9 min read
1/PSA--this just in--@CIGNA is engaging in systemic, multi-state actions & demanding immediate physician group contract reductions in the range of -30 to -50% (I have seen the emails in that range, see below for redacted copy); actions have been confirmed in #NC, #FL #TN &...... 2/ other states; @CIGNA is specifically referencing the #NoSurprisesAct as their justification for demanding immediate reductions or threatened unilateral termination, a 'la @BlueCrossNC (they tend to follow herd behavior) (as reported here but repeated again below)--redacted....
Jul 20, 2022 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....
Jul 15, 2022 5 tweets 3 min read
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…..
Jun 6, 2022 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....
Apr 1, 2022 6 tweets 9 min read
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".....
Feb 28, 2022 11 tweets 3 min read
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 ....
Nov 22, 2021 11 tweets 26 min read
@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....
Nov 13, 2021 4 tweets 8 min read
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 2/ @Reese_Tassey @813JAFERD @sonodoc99 @fuzzymittens @amychomd @ercoderguy @MarilynHeineMD @Valleus556 @mass_marion @A4Horg @CRCook1978 @ZachJonesForTX @ASAGrassroots @EmergencyDocs @RadiologyACR @AmerMedicalAssn @ahahospitals @teamhealth @EDPMA @KatieOrrico @GrassrootsEM
Sep 30, 2021 7 tweets 7 min read
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..
Sep 15, 2021 4 tweets 6 min read
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 ..
May 25, 2021 5 tweets 2 min read
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 …..
Apr 21, 2021 4 tweets 2 min read
@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.....
Dec 21, 2020 11 tweets 2 min read
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
Dec 11, 2020 7 tweets 7 min read
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"
Dec 1, 2020 4 tweets 6 min read
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.......
Nov 9, 2020 5 tweets 7 min read
@sonodoc99 @mssnytweet @CNBC 2/ @pfizer CEO on @CNBC said that they have 50M doses ready for ‘20 & 1.3B doses scheduled for ‘21 + no negative implications were reported yet the firm does not have visibility into the panel’s specific data set + Pt cohort ranges from 84 to 12 yrs. old.... @sonodoc99 @mssnytweet @CNBC @pfizer 3/ big thx to @BeckyQuick for expressing the emotions of tens of millions of your fellow citizens—the biggest & best news of the year!