Ed Gaines
@EdGainesIII
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#healthcare #attorney #physicians & #clinicians advocate, honorary member of #ACEP & co-founder #EDPMA , #tennis enthusiast & dad—posting as an individual
Greensboro, NC
Joined July 2012
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Pinned Tweet
As a subtle reminder: my tweets are my own; my employer or trade organizations where I am board member or speaker have nothing to with my tweets or the thoughts expressed therein.
#healthlawyertweets
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My PSA—Hello
@mcuban
—since you are dunking the pharma industry (based on your profile) why don’t you do the same for the “third party administrator” (TPA) industry as well? You could dominate the TPA industry inside of 3 years. Offer fair contract rates to physicians, hospitals…
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1/I have no word for this news…
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@amyfaithho
P.S. Before ACEP/EDPMA advocated 4 federal
#prudentlayperson
standards in the Balanced Budget Act of 1997, prior authorization =huge issue in EM. Pts. had to call their PCP for the “prior auth.” codes which they had to present to the ED. No studies known 2 me but believe Pts died
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This bi-partisan bill would link the
#Medicare
Physician Fee Schedule (MPFS) to the Medicare Economic Index (MEI) and if enacted before this year would have meant a +3.8% increase in the MPFS instead of the -2.1% cut in '23. As sh…
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Very interesting trend w/ large employers (fortune 150 company) + large labor unions suing their third party administrators (TPAs) claiming that the TPAs have enriched themselves at the cost of the beneficiaries of health insurance
@Aetna
@ElevanceHealth
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1/ So the bottom line is that with the -3.37% + RVU cuts for many non-primary care specialities + 4.6%+ medical inflation increase the real dollar cut is ~8-10%. House bill introduced to cancel 2024's physician pay cut
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1/ Is anyone on
#Medtwitter
talking about this as it would be the largest physician group union in the US? If they are, I missed it & appears to be a potential big deal.
@sonodoc99
? Allina Doctors File to Unionize
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18
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That’s $114.6M, 5 guys & 1 gal, averaging in at >$19M per person, while I hear heartbreaking reports of complete burnout from front line physicians, the 1 today from
@VituityHealth
Dr. Bing Pao—pay 4 each of these 6
#healthplan
CEOs surpasses $15M
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@crockpics
Actually it’s a JJ Cale song— LS’ version of “Call Me The Breeze”—Billy Powell’s piano solo is among the best in the 20th Century IMHO
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Another outstanding piece by
@propublica
on
@CIGNA
& really an extension of an earlier piece on the
#AI
/
#LLM
that the health plan developed to accelerate the denials of care.
“Deny, deny, deny. That’s how you hit your numbers,” said former Cigna medical director Dr. Debby Day about the pressure put on her to rapidly review patients’ cases. My latest on health insurance denials with
@PatrickMRucker
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1/This could be 1 of the more important cases to
@EmergencyDocs
& hospitals of ‘23 b/c the
@UHC
subsidiary UMR is the TPA for >2100 health plans. Allegations include ~10 yrs of violations of the
#prudentlayperson
stds.4 adjudication of
#ED
claims.
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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.....
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This is a significant finding on the facts and the law—that United Healthcare’s conduct was so egregious & fraudulent as the jury had previously found that $60M in punitive damages should be awarded now in this phase of the trial—congrats to Team Health!
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Well said--The
@FTC
appears to think physician groups have unreasonable market power vs. health plans if you read their complaint vs. USAP, whereas the primary focus should be on the unfair & deceptive trade practices (under the FTC Act) that the health plans engage in regularly.
Amidst the potential largest merger of the year,
@AHIPCoverage
@txhealthplans
members
@Cigna
's bid to acquire
@Humana
following its $54 Billion purchase of
@ExpressScripts
echoes past attempt by
@Aetna
’s blocked by the
@FTC
for stifling competition. Any further consolidation of…
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@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
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Thank you
@mass_marion
on behalf of America! Senate Finance Committee votes to impose drug pricing standards on PBMs
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17 yr hospital CEO in
#CT
is taking off the gloves vs.
#MedicareAdvantage
. The hospital’s Advantage denials are nearly 14% > than Medicare A & B FFS, so he laid off 60 folks from his hospital. There have been multiple posts here & elsewhere showing Advantage denials are out of…
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3/ major hospital based specialists will be significantly cut in’21 by Medicare in the midst of a global pandemic—
@emergencydocs
-6%, anesthesiologists-8%, radiology -11% and IR -9%. Congress &
@CMSGov
here they come—Table 90, page 899.
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Folks—don’t get mad—get politically active at your clinician level with your members of Congress + support your state, county and federal medical societies + your specialty society but don’t assume ONLY they will do the heavy lifting —you the individual Doc can make a huge impact
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1/The lawyer analogy is quite right—lawyers may own law firm but physicians cannot own hospitals? + this report shows cost savings. Could give
@MichaelCBurgess
proposal a major boost—Physician-owned hospitals could have saved $1.1B in 2019: report
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@TheTennisLetter
So great that
@CocoGauff
is giving credit & praise to the GOAT of all time
@serenawilliams
&
@Venuseswilliams
—an amazing level of maturity for a 19 YO—credit to her parents and family.
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Congratulations to
@TeamHealth
on its nearly $11M arbitration award against
@UHC
for underpayments over many yrs. This is in addition to the +$60M jury award last yr. in NV--8 more cases pending.
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17
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Glad we are all sitting down--
@UHC
healthcare division profits at $14.4B in '22 w/ revenues up +12% w/ nearly 27M commercial covered lives + significantly higher '23 revenues. Don't get mad--get active & advocate!
10
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We don't talk enough about the "double whammy" of the Medicare cuts of ~3.4% + how ill-fated & complete policy disaster program known as "MIPS" figures into potentially adding a -9% this yr. after many clinicians could claim exemption during the pandemic & the PHE.
"When…
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18
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Is it me or are
#hospitals
dropping
#MedicareAdvantage
plans like never before citing claims denials, prior auth. & slow reimbursements? Major
#DE
& South
#PA
system is the most recent.
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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....
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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….?
@drdanchoi
utm_source=twitter&utm_medium=social
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We have it on good authority & has been confirmed that the following is currently planned to be offered by the
@SpeakerPelosi
to
@senatemajldr
re:
#surprisemedicalbilling
: 1. the
#SMB
provisions have not been released per major physician & hospital organizations; 2. so we're....
4
15
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Putting aside the PE issues, any day
@UHC
loses in court to physicians is a good day—Radiology provider Envision Healthcare scores $91M judgment against UnitedHealthcare
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15
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Brain tumor removal denial has to be the most outrageous denial.
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15
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3/ client named email is below, received Mon. 7/25/22--I have seen or discussed w/ EM and anesthesia groups so far--likely more is coming & industry colleagues have shared term letters--also redacted and posted below--once again, time for a strong advocacy response from.....
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This is the lawsuit that revealed in sworn testimony the non-disclosed conflicts of interest that
@zackcooperYale
had & UHC's editorial involvement w/ the
@NEJM
studies on
#outofnetwork
&
#surprisemedicalbilling
--studies referred to by Congress & federal agencies as a basis 4 NSA
The Hearing to seal the damning UHC emails has been moved to 10:30am PST 12:30pm CST. UHC is trying to Seal the Court Room Because they don’t want you to see.
@AmerMedicalAssn
@AOAforDOs
@texmed
#MedTwitter
@ASAGrassroots
@ASALifeline
@ACEPNow
@RadiologyACR
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@neparutennis
@rogerfederer
This is so good & beyond words in any language —what player ever even tries for this shot let alone makes it—only 1 human has been so anointed—
@rogerfederer
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6/ I’m willing to consider a counter but it would need to be much closer to my original proposal.
Thank you" (this director's original proposal was a cut of -40 to -50% vs. contracted rates); here's the term letter from CIGNA and NC Blue Nov. '21 letter below that:
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Nope—and that’s after
@UHC
posted over $22B in net profit in ‘20 while you and your EM colleagues and care teams were placing your lives on the line.
I’m trying to think of another industry with record profits that just doesn’t pay its bills.
Anthem, UnitedHealthcare, other major insurers are running billions behind in payments to hospitals, doctors via
@USATODAY
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1/ So
@uhc
posted record 2020 net profits of $22.4B—let’s say there are 20 biz days in a month just for kicks & that is $93.33M per biz day net profit in the middle of global pandemic — $UNH overcomes pandemic hit and tops 4Q expectations via
@seattletimes
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1/ So
@UHC
provided data to Yale Prof. Zach Cooper, had editing, input & changes in the original paper & follow up that was then picked up in major media outlets--where's the COI disclosure? Where's the outrage? Where's the accountability
@WSJ
@NYT
@washingtonpost
? W/out......
“United also had the ability to edit and suggest changes to the paper’s drafts, and executives were kept up to date on the researchers’ goals and progress, the emails show.”
Academics and journalists are the best lobbyists because they seem unbiased.
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For those who don’t know this interview is the essence of
@rogerfederer
as another human on the planet—it’s not a statement of his life—but it truly reflects the class & humility that he has & it’s quite funny to hear.
🗣️ Roger Federer: "I have won this tournament eight times, please believe me!"
This is hilarious 😂
🎥 The Daily Show
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8K
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1/ All in the EM community, EMTALA on call docs & folks who care about the Prudent Lay Person (PLP) doctrine, we now have a court precedent that is a sterling decision finding a “downcoding list” used by a Medicaid program to be invalid under PLP AND that CMS acted arbitrary….
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Blue hydrangeas from my wife’s handy work are as beautiful as I have ever seen them—enjoy!
#ncsummer
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1/ After toiling in the
#prudentlayperson
health policy & advocacy fields since before we passed BBA '97
#PLP
protections, it is with great pleasure that I present to
@EmergencyDocs
&
#physicians
writ large perhaps the most definitive statement against
@UHC
@Centene
down-coding
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Per
@NoSurpriseGap
lobbyist just now--Senate leadership has taken the Pallone/Alexander proposal off of the table for the 3rd
#COVID19
relief bill (Phase 3 or 3.0) --social media made a big difference--congrats to all!! Pallone/Alexander are fully expected to try for May 22...
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This just in...
@UHC
crushed its yr. over yr. profits '21 over '20 by +42% in the insurance subsidiary, yet they continue to conduct wide spread ED physician coding/billing audits where they allow ZERO for ED care in the middle of global pandemic.
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@EdGainesIII
a Senator’s staffer point blank said to us “they (insurers, hospitals) just lobby better than you (doctors)”
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I view this as a partial failure of
#physician
advocacy--a "loss is a loss" or a "cut is a cut" just the same. We lost the opportunity to address
#Medicare
physician fee schedule by the end of last yr. despite very significant efforts. We knew we had a window in March & simply…
@politico
is reporting that the doc fix will be 1.68%, effective April 1.
A 1.68 percent fix for 9 months is nearly the equivalent of a 1.25 percent fix for the full year.
Still a significant cut for physicians…. Still a 1.69 percent cut for the rest of the year— while…
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This is will be a paramount
#SCOTUS
case for
@EmergencyDocs
. Whether
#EMTALA
preempts state laws that restrict abortion. Recall that traditionally the decision whether the Pt has an “emergency medical condition” (EMC) & is in need of stabilizing care is the sole province of the…
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5/ "Unfortunately that rate is no longer competitive due to the no surprise billing act. We are looking for rates similar to what you would be paid as OON via the new legislation and we’ve sent reductions to all of the ER groups using the same proposal that I sent you.......
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GM Mr. Cuban,
@mcuban
if you want Exhibits A-Z on how you should disrupt the
#thirdpartyadministrator
#TPA
business, read
@ChrisDHamby
’s outstanding investigative piece on
@MultiPlan_Inc
@UHC
’s nearly $51K admin fee on a ~$153K hospital bill where MP recommended & UHC allowed…
Multiplan is another scam; of course, it's owned by a PE firm. Insurers and Muliplan take a "fee" as a % of the amount of an OON bill that they "saved" the employer from paying. Granted... some OON docs charge rediculous fees... but that's not the point. The entire insurance…
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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..
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18
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Congrats to
@SenThomTillis
& colleagues to address the issues of “ghost networks”, citing a Senate study that many physician groups have experienced—that clinician directories are often inaccurate & the health plans suffer no consequences for same.
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Excellent article Dr. Sandeep Jauhar—“The healthcare sector spends $265 billion annually on unnecessary regulatory and administrative tasks, more than the U.S. spends on either cancer or heart disease. Insurers, medical societies & gov’t regs. =to blame”
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4/ multiple stakeholders; readers here will know that in addition to the
@BCBSAssociation
plans,
@UHC
has engaged in similar behavior; frankly this a bit uncharacteristic of
@CIGNA
based on my experience--here's their email:
[Client Name Deleted]
Thank you for your response.
..
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1/ Word around the campfire (haven't seen the opinion yet) is that
@texmed
won their 2d case in fed. ct. challenging the
#NoSurprisesAct
final rule issued by the "Tri Depts" after the same judge vacated their first rule--folks this is completely unprecedented for a judge to ....
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@elindau
@mcuban
Fair rates w/ no gamemenship on prior auth., denials, unreasonable record requests, violations of
#prudentlayperson
& all of the rest—I could go on but will hit the key points.
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Whatever shred of credibility
@UHC
had w/ clinicians & hospitals--a very poor reputation earned long before this cyberattack & via many interactions--is gone.
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Good news that the physician mental health bill named for
@EmergencyDocs
Dr. Lorna Breen has passed —House passes clinician mental health bill
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@Wimbledon
@DjokerNole
There’s only 1 human in the world who could make that shot & its
@DjokerNole
— big congrats to him, his family & team!
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Albeit preliminary, an independent arbitrator has ruled in
@Rad_Partners
favor vs.
@UHC
& that’s good news. Underpayments are most of the award + prompt pay violations + attny fees—UHC owes Rad Par affiliate $153.5M in underpayment dispute, arbitration panel rules.
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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...
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The
@propublica
stories in '23 on the weaponization of denial bots/algos & machine learning clearly show that
#healthplans
are moving way beyond prior auth. They are routinely violating
#prudentlayperson
in
#IN
#GA
#FL
w/ Medicaid managed care entities (MCE). The MCE receives a…
🎇Must watch:
Denying Your Medical Care is Big Business in America -
@nytimes
How health insurers weaponize prior authorization.
🎥
#FixPriorAuth
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1/ This year's federal gov't "Grinch Award" has to go to the "Tri Depts" (HHS, Labor & Treasury) responsible for the implementation of the
#NoSurprisesAct
--they issue the following report after COB 12/23/22 + on the backs of announcing that the non-refundable NSA admin. fee....
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4/ The bottom line--this bill--subject to seeing the actual language--is WAY better than the E&C bill in the Spring of '19 & later the Pallone/Alexander compromise--so all you advocates out there--maybe you doubted "that 1 doctor could make a difference"--feel good that u did!!!
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Thank you Jeff for that detail. Collectively we need to review the carve out for non-profit hospitals as that exception would be a gaping loophole.
Earlier today, the
@FTC
voted 3 to 2 in favor of banning non-compete clauses in all employer/employee contracts, with no exceptions. Along with the vote, the FTC has issued a final rule, finalizing it proposal from January 2023 to ban non-compete clauses.
The effective date of…
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Little brother
@Cigna
top 5 executives were paid a total of $48M in ‘23, w/ CEO receiving over $21M. Now we know why they have repeatedly threatened or actually cut out of sequence hospital physician participation agreements aggressively pre-
#NoSurprisesAct
& post.…
1
19
35
@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.
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Simply incredible that
@UHC
Optum would offer a loan of this nature given the size of the physician’s practice!
Everyone needs to see how absolutely horrible this situation is. $UNH I doubt anyone (doctors, pharmacists or nurses) will receive the largess that
@UHC
plan on paying out in dividends. AW would never cut dividends to support the
#healthcareheroes
who make healthcare work.
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Physician stakeholders should embrace & advocate for inflation adjustments in the Medicare fee schedule that have not been part of RBRVS since its creation in 1992--the Medicare physician fee schedule is down vs. CPI-U over 60% in…
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@WeAreTennis
Easy—
@Wimbledon
as then you may become a member of one of the most exclusive clubs in the world, not just tennis.
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1/For Q1-Q3 2023, the top 6 health plans had over $11B in net profits. But don’t ask them about the costs of healthcare, or compliance w/
#NoSurprisesAct
IDR decisions against them or not taking high single or low double digit > in premiums—costs too much
1
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3/ Here’s a companion piece to
@ChrisDHamby
remarkable investigative story. 2 key takeaways:
@UHC
made over $1B off of the
@MultiPlan_Inc
& related firms “out of network savings program” + MP employees were of course incentivized on their bonuses which were tied to locking in…
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36
ACEP, ASA & ACR filed suit in federal court in Chicago challenging the Administration’s Sept. final rule that creates a defacto benchmark payment standard at the health plan’s median allowed amount—non-transparent to all others—und…
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Nope that's not a typo--
@AnthemBCBS
the very same health plan being sued in fed. court by
@ACEPNow
& Medical Association of GA for non compliance w/ prudent lay person laws due to their diagnosis lists--Q3 report shows Anthem profits >580%: 5 things 2 know
3
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1/ From the "you can't make this up" file,
@CMSGov
has 3 "independent dispute resolution entities" (IDREs) (nearly 1/3 of the total IDREs) under the
#NoSurprisesAct
that have flatly stated on the CMS website that they are not taking any new IDR disputes (see below) + physician...
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1/From the "truth is stranger than fiction" files, here's a subsidiary of
@UHC
that offers services to address out of network claims under the
#NoSurprisesAct
. Now you won't find it there but it is in official gov't reports that UHC is the
#1
health plan that clinicians file....
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Thank you Dr. Panthagani for calling out the faulty & flawed
@HHSGov
AHRQ “research” on emergency medicine—New Study Sounds a False Alarm About Emergency Rooms by
@kmpanthagani
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@annabroadaway
@CriminelleLaw
That’s the most sensible thing anyone has said—it’s hard not to be outraged—and I’ve been in house for 30 yrs. so what do I know about it?
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More
#MedicareAdvantage
issues as the MA denial % is higher than the commercial health plan % per a survey of Premier
#hospital
members. Medicare Part A denial % cannot be close to 15%—don’t have those
#s
handy but the Part B
#s
have to be in the single digits.…
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Since the creation of the
#RBRVS
system &
@CMSGov
physician fee schedule in 1992, the Medicare physician fee schedule is down in real dollar terms (adjusted for inflation) over -60%—Medicare was never intended to be representative of fair & appropriate reimbursement but plans try
@matthewtaber
@misterchambo
@rgergelymd
@PtRightsAdvoc
@notaproviderMD
@GallaherCaren
@EdGainesIII
@mass_marion
@LeahHoustonMD
@ShawnNeedham2
@CFroh
Well most docs can’t actually run a business on Medicare prices… compared to costs and inflation we have actually taken a pay cut over the years. Financial compensation should be tied to the Value you deliver even in Medicine. Healers have families and expenses too.
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1/90% of over 350 physician group practices cite prior auth., the
@CMS
.Gov
#MIPS
program & the
#NoSurprisesAct
for increased regulatory burden—Practices say regulatory burdens increased over last 12 months
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Jury’s finding of fraud vs.
@UHC
is significant as is their finding of punitive damages, not to mention the exposure of significant conflicts of interest w/
@zackcooperYale
w/ his purported “studies” of
#surprisemedicalbilling
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@WakeForest
(left) & our son graduating from
@UNC
(right) but we could not be more proud —we’ll take
#housedivided
any day so today its
#GoHeels
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1/
@UHC
deploying proprietary AI/ML + other criteria allegedly to deny
#MedicareAdvantage
services that would otherwise be covered under Medicare FFS—Hospitals: UHC's MA policy 'blatantly violates' CMS requirements
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Wait, stop the presses—yet another (is it 4 or so in the last ~ month?) major health system is out of network w….wait for it…
@UHC
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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 .....
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