Ed Gaines Profile picture
#healthcare #attorney #physicians & #clinicians advocate, honorary member of #ACEP & co-founder #EDPMA, #tennis enthusiast & dad—posting as an individual
Apr 1 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 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!
Sep 24, 2020 5 tweets 4 min read
1/ POTUS Executive Order (EO) is potentially back on & here’s the outline on the terms & conditions—the EO has been drafted—whether he announces it in the Queen's City today & that he’ll sign it is another open issue: #medtwitter
1. The prohibition on surprise medical billing... 2/ will be linked to the hospital’s conditions of participation (CoPs);
2. By law, physicians do not have CoPs—hospitals have them—so this may be an immediate potential legal argument against his actions;
3. The EO would pit hospitals against the physicians credentialed....
Sep 22, 2020 5 tweets 2 min read
1/ As reported in PoliticoPro –
Trump preparing executive orders on health care this week
By Susannah Luthi, Daniel Lippman, Dan Diamond
09/22/2020 02:51 PM EDT
President Donald Trump is planning to announce a series of executive actions on health care as soon as Thursday... 2/ & one EO is expected to be on #surprisemedicalbilling --been rumored for months & details are not known--last WH idea was outright ban on OON/BB w/ no mechanism for physicians & health plans to resolve $ disputes but Pts would be protected--WH COS Meadows was against ....
Sep 17, 2020 6 tweets 8 min read
1/ So the #TX health plans--after supporting the solution to #surprisemedicalbilling which passed unanimously--are now pointing fingers--lets consider the facts--1. per the TX Dept. of Insurance (TDI), when clinicians informally settle their dispute before the formal dispute .... 2/ resolution process (IDR), the plans are settling for 4X of the original reimbursement paid; when clinicians go thru the IDR process, the independent dispute adjudicator is awarding >5.3X of the plan's initial reimbursement--based on TDI's report of the 1st 6 months--see charts
Aug 4, 2020 9 tweets 7 min read
@CMSGov issued ‘21 Medicare #Physician Fee Schedule Proposed Final Rule w/ comment period & the news is not good —the Medicare “conversion factor” which applies to physicians & other clinicians is proposed to decline >10.5% in ‘21—happy reading > 1350 pgs
cms.gov/files/document… Image 2/ Major expansion of #telehealth per the press release, details to follow.
Aug 2, 2020 4 tweets 3 min read
Good luck to my good friend @lukebjensen & @nyempiretennis to take the King Trophy, doesn’t hurt to have #tennis HOF Kim Clijsters pictured here & out of retirement and crushing the ball! How about Coach Jensens sub of Jack Sock who lit up that mixed doubles final w/ @CoCoVandey who held serve like a true champ at the end!
Jul 28, 2020 4 tweets 2 min read
Yet another example of perhaps well meaning legislators who do not understand these dynamics rushing to get a really bad bill on #surprisemedicalbilling passed the #MI Senate--HB 4459 is bench-marking in the worst way + no meaningful & accessible dispute resolution; Senate ... 2/ MI Senate consideration in committee is 7/29/20 (last minute move by supporters to push through a bad bill for health plans) so we need groups & docs to do calls to action--physician coalition is multi-specialty & unified in opposition--see below--@MichStateMedSoc @MCEP_NEWS
Jun 17, 2020 4 tweets 3 min read
1/ Big congrats to @FairCoverage @MAG1849 @michelekimball @DPalmisanoMAG @GAemergency
Dr. Brett Canno on the passage of #GA HB 888 – The Surprise Billing Consumer Protection Act, passed the Senate today--ends surprise medical billing 4 Georgia Pts. w/ fair & accessible IDR... 2/ & preserving their access to care. The bill includes the following: 1. Strong Patient Protections: no OON billing;
2. Fair Reimbursement: for OON care or services is set at the median in-network amount paid in 2017 for emergency or nonemergency services & CPI adjusted..
Jun 2, 2020 4 tweets 3 min read
1/Here we go again--in the midst of the #COVID19 when @EmergencyDocs are in harms way for all of us, #healthplans @Amerigroup in this case can't help themselves from using illegal diagnosis lists/algos/bots that key off final diagnoses--expressly not allowed by @CMSGov ... 2/ 2 flag both #outofnetwork & in-network claims (is the delay on the latter a cynical attempt 2 force contracting?)--4 chart review to determine #prudentlayperson status or not--if deemed "non-emergent" then a triage fee is paid--& if no records or so they claim then triage fee
May 28, 2020 7 tweets 6 min read
@LorenAdler Surely you'll remember CA Medical Association letter 2 the E&C committee last yr--if not, let me refresh your recollection--& where is the evidence that premiums in CA went down over 4 yrs? No one has produced that evidence have they? @CMAdocs cited numerous examples... @LorenAdler @CMAdocs 2/ of networks & physician Ks being cut, Pt access to care being limited... all of the ills of your simple solution are in full relief there..