Podcasts about current procedural terminology

Can Therapists Start a Union? The Antitrust Trap, the Shadow Committee, and the Economic Strangulation of American Psychotherapy Analyzing America's Healthcare Regulations and Their Effect on Us: Why the Law Prevents Therapists from Organizing While Allowing a Private Committee to Fix Prices for the Entire Medical System https://gettherapybirmingham.com/can-therapists-start-a-union-spoiler-alert-they-cant/ The Monthly Rage Thread If you hang around therapist forums long enough, you will see it happen. It operates with the regularity of the tides. Someone posts a thread, usually after receiving a contract from an insurance company offering 1998 rates for 2025 work, and asks the obvious question: “We are the ones providing the care. The system collapses without us. Why don't we just all go on strike? Why don't we form a union and demand fair pay?” It is a logical question. In almost every other sector of the economy, workers who feel exploited band together to negotiate better terms. Screenwriters shut down Hollywood to get paid for streaming residuals. Auto workers walk off the line. Teachers fill the state capitol. Nurses at major hospital systems have successfully unionized and won significant concessions. So why, in the midst of a national mental health crisis, does the mental health workforce remain so politically impotent? The answer is not that we lack will. It is not that we lack organization. The answer is that for private practice therapists, forming a union is a federal crime. This is not a political manifesto. It is an analysis of the bizarre regulatory environment that governs American healthcare, a system of antitrust laws, shadow committees, and bureaucratic classifications that effectively strips clinicians of their bargaining power while empowering the corporations that pay them. If you want to understand why corporate tech monopolies are ruining therapy, or why the corporatization of healthcare feels so suffocating, you have to understand the legal straitjacket we are all wearing. And you have to understand the one group that is allowed to set prices, the one group exempt from the rules that bind the rest of us. Part I: You Are Not a Worker, You Are a Standard Oil Tycoon The primary reason therapists cannot unionize dates back to the era of oil barons and railroad tycoons. The Sherman Antitrust Act of 1890 was designed to prevent massive corporations like Standard Oil from colluding to fix prices and destroy the free market. It prohibits “every contract, combination… or conspiracy, in restraint of trade.” The law was a response to genuine abuses: companies buying up competitors, dividing territories, and coordinating prices to gouge consumers who had no alternatives. Here is the catch: In the eyes of the federal government, a private practice therapist is not a “worker.” You are a business entity. Even if you are a solo practitioner struggling to pay rent in a subleased office, seeing clients between crying in your car and eating lunch at your desk, the law views you as the CEO of a micro-corporation. You are classified as a 1099 independent contractor, not a W-2 employee, and that distinction makes all the difference in the world. If two workers at Starbucks talk about their wages and agree to ask for a raise, that is “collective bargaining,” which is protected by the National Labor Relations Act. But if two private practice therapists talk about their reimbursement rates and agree to ask Blue Cross for a raise, that is “price-fixing.” It is legally indistinguishable, in the eyes of the Federal Trade Commission, from gas stations conspiring to raise the price of unleaded. It sounds absurd, but the FTC takes it deadly seriously. When independent contractors organize to demand higher rates, when they share information about what they are being paid and coordinate their responses, they are engaging in horizontal price-fixing, one of the most serious violations of antitrust law. The Sherman Act provides for criminal penalties, including fines and imprisonment. The law that was meant to break up monopolies is now used to prevent social workers from asking for a cost-of-living adjustment. The irony is crushing. The same regulatory framework that prevents two therapists from discussing their rates allows massive insurance conglomerates to merge repeatedly, concentrating buyer power in fewer and fewer hands. UnitedHealth Group, for example, has acquired dozens of companies over the past two decades, becoming the largest healthcare company in the United States. When they offer a “take it or leave it” contract to providers, they do so with the full knowledge that fragmented, legally prohibited from organizing therapists have no counter-leverage. The antitrust laws, designed to prevent monopoly power, have created a system where sellers are atomized and buyers are consolidated. Economists call this “monopsony,” and it is precisely the market distortion the Sherman Act was supposed to prevent. Part II: The Day the “Learned Profession” Died For a long time, doctors and lawyers thought they were exempt from these laws. They argued that they were “learned professions,” not mere tradespeople, and therefore above the grubby laws of commerce. They believed that their ethical obligations to patients and clients set them apart from the rules that governed steel mills and meatpacking plants. Medicine was a calling, not a business, and surely the government would not regulate the sacred doctor-patient relationship as if it were a commercial transaction. That illusion was shattered in 1975 by the Supreme Court case Goldfarb v. Virginia State Bar. The case involved lawyers, not doctors, but its implications cascaded through every licensed profession in America. The Goldfarbs were purchasing a home and needed a title examination. The Virginia State Bar had established a minimum fee schedule for such services, and every lawyer they contacted quoted the exact same price. They sued, arguing that this fee schedule was illegal price-fixing. The Supreme Court agreed. In a unanimous decision, the Court ruled that professional services, including legal and medical advice, are “trade or commerce” subject to antitrust laws. The “learned profession” exemption, which had been assumed but never explicitly established in law, was declared a myth. “The nature of an occupation, standing alone,” the Court wrote, “does not provide sanctuary from the Sherman Act.” This ruling was intended to lower prices for consumers by preventing lawyers from setting minimum fees, and in that narrow sense it was a good thing. But in healthcare, it had a catastrophic side effect: it made it illegal for doctors and therapists to band together to resist the pricing power of insurance companies. The “learned profession” exemption is dead. We are now just businesses, and businesses are not allowed to hold hands. This creates the illusion of progress: we have “free market” competition among providers, but monopsony power among payers. It is a market where the sellers are forbidden from organizing, but the buyers are allowed to merge until they are too big to fail. The result is not a free market at all. It is a market designed to transfer wealth from one class (providers) to another (insurers and administrators), with the law itself serving as the enforcement mechanism. Part III: The Cartel in the Basement If therapists cannot collude to set prices, surely nobody else can, right? Wrong. There is one group in American healthcare that is allowed to meet in a room, decide what every doctor's time is worth, and set prices for the entire industry. It is called the RUC, the AMA/Specialty Society Relative Value Scale Update Committee. And understanding the RUC is the key to understanding why talk therapy is dying in the medical model, why psychiatrists abandoned the couch for the prescription pad, and why your insurance company offers you a ghost network of providers who never answer the phone. The Birth of a Shadow Government To comprehend the current crisis in mental health economics, one must excavate the foundations of the physician payment system. Prior to 1992, Medicare reimbursed physicians based on a system known as “Customary, Prevailing, and Reasonable” charges. Under this system, physicians were paid based on their historical billing charges. It was inherently inflationary; it rewarded those who raised their fees most aggressively and created wide geographic disparities for identical services. In response to spiraling costs, Congress passed the Omnibus Budget Reconciliation Act of 1989, mandating a transition to a fee schedule based on the resources required to provide a service. This birthed the Resource-Based Relative Value Scale. The intellectual architecture for this system was developed by a team of economists at Harvard University, led by William Hsiao. Hsiao's team sought to create a “unified theory” of medical value, attempting to quantify the “work” involved in disparate medical acts, comparing the cognitive intensity of a psychiatric evaluation with the technical skill of a hernia repair. The Harvard study was revolutionary. It promised to level the playing field, suggesting that cognitive services, the thinking and talking that comprises primary care and mental health, were vastly undervalued relative to surgical procedures. Had Hsiao's original recommendations been implemented purely, the income gap between generalists and specialists might have narrowed significantly. But the administrative complexity of assigning values to over 7,000 Current Procedural Terminology codes overwhelmed the Health Care Financing Administration. Into this administrative vacuum stepped the American Medical Association. The AMA, fearing that the government would unilaterally set prices, proposed a “partnership.” They would convene a committee of experts to maintain and update the relative values, providing this labor-intensive service to the government at no cost. The government accepted. Thus, in 1991, the RUC was born, not as a government agency, but as a private advisory body with unparalleled influence over public funds. The Architecture of Control The RUC's claim to legitimacy rests on its status as an “expert panel.” But a structural analysis of its composition reveals a profound bias that mimics the governance of a cartel designed to protect incumbent interests. The committee consists of 32 members, but power is concentrated in the 29 voting seats. Of these, 21 seats are appointed by major national medical specialty societies. The distribution is not proportional to the volume of services provided to Medicare beneficiaries, nor is it proportional to the physician workforce. Instead, it is frozen in a historical moment that favored high-technology specialties. Primary care physicians, who perform roughly 45 to 50 percent of Medicare work, hold approximately 4 to 5 seats, giving them about 17 percent of the vote. Procedural and surgical specialties, including surgery, radiology, and anesthesiology, hold 15 to 18 seats, giving them roughly 60 percent of the vote despite performing only 35 to 40 percent of Medicare work. The American Psychiatric Association holds a single seat. One seat. This lone representative must negotiate with a supermajority of specialists, neurosurgeons, cardiothoracic surgeons, radiologists, and ophthalmologists, whose financial interests are often diametrically opposed to the valuation of cognitive work. The cartel dynamic is enforced by a statutory requirement of budget neutrality. The Medicare Physician Fee Schedule is a zero-sum game. If the total relative value units projected for a given year exceed the budget, a “scaler” is applied to reduce the conversion factor, effectively cutting everyone's pay. Therefore, any proposal to increase the value of psychotherapy, which would increase the total RVU spend, effectively asks every surgeon in the room to take a pay cut to fund the raise for psychiatrists. Given that a two-thirds majority is required to pass a recommendation, the procedural bloc holds absolute veto power over any redistribution of wealth. The Secret Chamber A hallmark of cartel behavior is the restriction of information. For nearly two decades, the RUC operated in near-total secrecy. While recent years have seen minor concessions to transparency, such as the publication of vote totals, the core deliberative process remains opaque. RUC meetings are private. The public, the press, and even non-RUC physicians are largely barred from attending the deliberations where billions of tax dollars are allocated. Participants, including the specialty advisors who present data, must sign strict non-disclosure agreements. These agreements prevent them from discussing the specific tradeoffs, deals, or arguments made within the chamber. A former RUC participant described these agreements as “draconian,” designed to insulate the committee from public accountability. The Government Accountability Office and the Center for American Progress have noted the inherent conflict of interest. The individuals setting the prices are the same individuals who receive the payments. Unlike a regulatory agency, where officials are salaried and divested of industry assets, RUC members are practicing physicians whose personal incomes are directly tied to the decisions they make. This secrecy serves a functional purpose: it allows for “logrolling.” A representative from Orthopedics might support an inflated value for a Cardiology code in exchange for Cardiology's support on a Knee Replacement code. This “I'll scratch your back” dynamic creates an upward pressure on procedural values that excludes those outside the dominant coalition, specifically primary care and mental health. The Antitrust Shield Why has the Department of Justice not broken up this cartel? The legal shield is the Noerr-Pennington Doctrine. This Supreme Court doctrine establishes that private entities are immune from antitrust liability when they are petitioning the government. Because the RUC technically only “recommends” values to CMS (that is petitioning), and CMS “decides” (that is government action), the RUC is protected by the First Amendment right to petition. This legal loophole allows the RUC to operate with monopolistic characteristics without fear of prosecution, provided CMS continues to go through the motions of “reviewing” the recommendations. And CMS accepts those recommendations over 90 percent of the time. Because private insurance companies generally base their rates on Medicare, this private committee effectively sets the price of healthcare for the entire country. If independent therapists did this, if they gathered in a room and agreed on what their services should cost, they would face criminal prosecution. But because the RUC operates under the fiction of “advising” the government, it is protected. The same regulatory framework that criminalizes therapist solidarity provides cover for industry-wide price coordination by the most powerful medical specialties. Part IV: The Mechanics of Suppression To control a market, one must control its currency. In American medicine, that currency is the Relative Value Unit. Every medical service, from a 15-minute therapy session to a heart transplant, is assigned a total RVU value. This value is the sum of three components: the Work RVU, which accounts for physician time, technical skill, mental effort, and judgment; the Practice Expense RVU, which covers overhead costs like rent, staff, and equipment; and the Malpractice RVU, which reflects professional liability insurance costs. The Work RVU, which comprises roughly 50 to 55 percent of the total value, is determined by RUC surveys. When a code is flagged for review, the relevant specialty society distributes a survey to a sample of its members. These respondents are asked to estimate the time and intensity of the service compared to a “reference service.” This methodology violates several principles of statistical validity. The surveys are voluntary and distributed by the specialty societies themselves. The respondents are typically those most active in the society and most invested in maximizing reimbursement, advocates rather than neutral observers. The sample sizes are often shockingly small; RUC surveys frequently rely on fewer than 50 or 70 respondents to set the price for services performed millions of times annually. A sample of 30 orthopedic surgeons might determine the value of a procedure costing Medicare billions. The Time Arbitrage The most critical variable in the RUC equation is time. The Work RVU is conceptually derived from the formula: Work equals Time multiplied by Intensity. Therefore, inflating the time estimate is the most direct route to inflating the price. Independent studies by RAND and the Urban Institute, often using objective data like Operating Room logs, have consistently shown that the RUC overestimates the time required for surgical procedures. A procedure valued by the RUC as taking 60 minutes may, in reality, take 30 minutes. This creates an arbitrage opportunity. If a gastroenterologist can perform a “60-minute” colonoscopy in 20 minutes, they can effectively perform three procedures in the time allotted for one. They bill for three hours of work in one hour of real time. This “efficiency gain” is captured entirely by the physician as profit. Psychotherapy cannot utilize this arbitrage. CPT codes for psychotherapy are explicitly time-based in their definition. Code 90832 requires 16 to 37 minutes. Code 90834 requires 38 to 52 minutes. Code 90837 requires 53 minutes or more. A psychiatrist cannot perform a 60-minute therapy session in 20 minutes; doing so constitutes fraud. Therefore, the revenue of a psychotherapist is capped by the linear passage of time. They can sell, at maximum, roughly 8 to 10 units of labor per day. A proceduralist, aided by RUC-inflated time assumptions, can sell 20 or 30 units of “RUC time” in the same day. This structural discrepancy creates a widening income gap that no amount of “hard work” by the therapist can close. It is not a market failure. It is market design. The “Thinking” Penalty The RUC's bias is not merely structural; it is philosophical. The committee, dominated by surgeons and proceduralists, consistently values “doing things to people,” cutting, scanning, injecting, far more highly than “talking to people,” diagnosing, counseling, managing complex chronic conditions. This creates a regulatory environment that functions as a de facto wealth transfer from cognitive care to procedural care. In 2013, a major revision of psychiatry codes exposed this bias in stark relief. Previously, psychiatrists used codes that bundled the medical evaluation with the psychotherapy. The new system required psychiatrists to bill an E/M code for the medical management plus an “add-on” code for psychotherapy. While intended to improve transparency, this change exposed psychotherapy to the raw mechanics of the RUC's valuation bias. By isolating the “therapy” component, the committee could subject it to rigorous cross-specialty comparison. And the committee, dominated by surgeons, views “talking to a patient” as low-intensity work compared to “operating on a patient.” The economic signal was clear. This created the 15-minute med check culture not because psychiatrists stopped caring, but because the regulatory environment made relational care financial suicide. It effectively “illegalized” the practice of deep, slow psychiatry for anyone who wanted to take insurance. Part V: The “Messenger Model” and Other Legal Fictions When therapists ask about collective bargaining, lawyers will often point them to the only legal loophole available: the “Messenger Model.” In this model, a third party (the messenger) acts as an intermediary between a group of providers and an insurance company. The messenger takes the insurance company's offer and conveys it to each therapist individually. Each therapist must then make a unilateral, independent decision to accept or reject it. The messenger is strictly forbidden from negotiating. They cannot say, “The group rejects this.” They cannot say, “We want 10% more.” They cannot advise the therapists on what to do. They can only carry messages. This is why “Independent Practice Associations” are often toothless. In the 2008 case North Texas Specialty Physicians v. FTC, the Fifth Circuit Court of Appeals made clear that if an IPA actually tries to leverage its numbers to demand better rates, it violates antitrust laws. If it follows the messenger model, it has no leverage. It is a “heads I win, tails you lose” regulatory structure designed to protect payers, not providers. The only exception is “clinical integration,” where providers genuinely merge their practices, share infrastructure, and accept joint financial risk. But this requires substantial capital investment and essentially means ceasing to be an independent practitioner. It is a legal pathway available mainly to large physician groups and hospital systems, not to solo therapists working out of rented offices. Part VI: Market Distortions and the Flight to Cash When a cartel sets a price below the market equilibrium, suppliers exit the formal market. This is precisely what has happened in psychotherapy. Mental health providers generally have lower overhead than surgeons. They do not need MRI machines or sterile surgical suites. And they face high consumer demand; the national mental health crisis ensures a steady stream of people seeking services. This gives them an “exit option” that proceduralists do not have. They can refuse to accept insurance and operate as cash-only businesses. The statistics are stark. Nearly 50 percent of psychiatrists do not accept commercial insurance, compared to less than 10 percent of other specialists. A 2023 survey indicated that 64 percent of private practice therapists planned to increase their cash-pay rates. Research published in Health Affairs Scholar found that patients are 10.6 times more likely to go out-of-network for mental health care than for medical/surgical care. This mass exodus is a rational economic response to RUC-suppressed rates. If the RUC says an hour of therapy is worth $100 via the RVU-to-dollar conversion, but the market demand is willing to pay $250, the provider will leave the RUC-controlled sector. They are not abandoning their profession; they are abandoning a pricing regime that values their work at less than half its market rate. Ghost Networks The RUC's pricing failure creates “Ghost Networks,” directories filled with providers who are ostensibly “in-network” but are functionally inaccessible. They are either full, not accepting new patients, retired, have moved, or simply do not respond to inquiries from insurance-based patients because the administrative burden of prior authorizations and clawbacks outweighs the suppressed fee. This is not a “shortage” of providers in the absolute sense. There is no shortage of therapists in private practice. There is a shortage of therapists willing to work at the RUC-determined price point. The insurance directories are graveyards of phantom availability, creating the illusion of access where none exists. The Cost Paradox The central thesis of the RUC's defenders is that they “control costs.” By strictly managing RVUs, they claim to save taxpayer money. In psychotherapy, this logic backfires catastrophically. By suppressing reimbursement rates to a level that drives providers out of the network, the RUC forces patients into the cash market. The theoretical in-network cost might be a $20 copay with the insurer paying $100. The actual out-of-network cost is $250 cash out-of-pocket, paid in full by the patient. Thus, the “cost of therapy” for the consumer skyrockets. Therapy becomes a luxury good, accessible only to those with disposable income. For the poor and middle class, the “cost” is effectively infinite, because the service becomes inaccessible. The RUC's cost-control measure for the system becomes a cost-multiplier for the patient. It shifts the financial burden from the risk pool, where it belongs, to the individual, where it causes maximum harm. The Signal to Students The RUC sends powerful economic signals to medical students making career decisions. When a student observes that a dermatologist or radiologist can earn $500,000 working regular hours, while a psychiatrist earns $240,000 handling emotional trauma and on-call emergencies, while a primary care doctor earns even less, the choice is clear for those motivated by financial security. The undervaluation of cognitive codes discourages the best and brightest from entering mental health and primary care. The cartel's pricing structure creates a perpetual labor shortage in the fields most needed for public health, while creating a surplus in high-margin procedural specialties. We then wonder why there are not enough psychiatrists, why primary care is in crisis, why mental health access is collapsing. The answer is in the price signal, and the price signal is set by a committee of proceduralists meeting behind closed doors. The Hands Are Tied The question “Why can't therapists start a union?” is not just a labor question. It is a window into the broken soul of American healthcare. We have built a system where a secret committee of proceduralists can legally fix prices to favor surgery over therapy, but a group of social workers cannot band together to ask for a living wage. We have utilized laws meant to break up Standard Oil to break up the solidarity of caregivers. The same regulatory framework that criminalizes therapist coordination provides legal cover for industry-wide price coordination by the most powerful medical specialties. The result is a regulatory environment that drives doctors crazy, burns out therapists, and leaves patients navigating a fragmented, assembly-line system that was never designed to heal them. It was designed to process them. Until we confront the legal architecture of this system, the RUC, the Sherman Act, the 1099 trap, we will remain powerless to change it. And the reality of therapy is that quick fixes, whether in treatment or in policy, usually end up costing us more in the end. Some states are beginning to push back. New York and California have implemented strict network adequacy standards requiring mental health appointments within 10 business days. These regulations force insurers to expand their networks, which means they must attract providers, which means they must raise reimbursement rates above the RUC/Medicare floor. It is effectively a state-level override of the RUC cartel, forcing capital back into the mental health labor market. The Medicare Payment Advisory Commission has long advocated for stripping the RUC of its power, proposing the use of empirical data, tax returns, payroll records, practice invoices, to set values automatically. But these are patchwork solutions to a systemic problem. The fundamental issue remains: we have created a healthcare system that knows the price of everything and the value of nothing. We have engineered a system where the only way to survive is to stop acting like a healer and start acting like a factory. And we have wrapped this system in a legal framework that criminalizes resistance while protecting the status quo. The hands are tied. But at least now we can see the ropes. Bibliography For those interested in the primary sources and legal texts that underpin this analysis, the following external resources provide high-trust verification of the claims made above: Goldfarb v. Virginia State Bar, 421 U.S. 773 (1975): The Supreme Court decision that ended the “learned profession” exemption from antitrust laws. Read the Oyez Summary. The Sherman Antitrust Act (15 U.S.C. §§ 1–7): The foundational text of US antitrust law prohibiting restraint of trade. Read the Document at the National Archives. North Texas Specialty Physicians v. Federal Trade Commission (5th Cir. 2008): A key ruling establishing that independent physicians cannot collectively bargain on fees without financial integration. Read the Court Opinion. FTC/DOJ Statements of Antitrust Enforcement Policy in Health Care (1996): The federal guidelines explaining the “Messenger Model” and the narrow exceptions for clinical integration. Read the Guidelines (PDF). The RUC (AMA/Specialty Society RVS Update Committee): The AMA's own description of the committee structure and its role in valuing physician work. Visit the AMA RUC Page. “Special Deal” by Haley Sweetland Edwards (Washington Monthly, 2013): An investigative deep-dive into how the RUC operates and its impact on primary care vs. specialty pay. Read the Investigation. The National Labor Relations Act (NLRA): The law governing the right to unionize, which specifically excludes independent contractors. Read the NLRA. Laugesen, Miriam J. Fixing Medical Prices: How Physicians Are Paid. Harvard University Press, 2016. The definitive scholarly analysis of the RUC's history, structure, and influence on American healthcare pricing. Government Accountability Office. “Medicare Physician Payment Rates: Better Data and Greater Transparency Could Improve Accuracy.” 2015. GAO's critical analysis of RUC methodology and conflicts of interest. Center for American Progress. “Rethinking the RUC.” 2015. Policy analysis of the RUC's structural bias against primary care and cognitive services. Health Affairs Scholar. “Insurance Acceptance and Cash Pay Rates for Psychotherapy in the US.” 2023. Empirical research on out-of-network utilization in mental health care. Medicare Payment Advisory Commission (MedPAC). “Report to the Congress: Medicare and the Health Care Delivery System.” 2024. Annual policy recommendations including proposals for reforming physician fee schedule methodology. Joel Blackstock, LICSW-S, is the Clinical Director of Taproot Therapy Collective in Hoover, Alabama. He specializes in complex trauma treatment and writes at GetTherapyBirmingham.com.  

What is value-based care? How does value-based care work? How to optimize value-based care? What is population health management? What is cost control in healthcare? Our guest is Lori Prestesater, senior vice president of Health Solutions at the American Medical Association, discusses the evolution of value-based care delivery and the the three pillars of value-based care: population health and quality management, cost management, and alternative payment models. She shares CPT code news and examples of CPT code changes in healthcare payment models, like the rise of digitally enabled care during the COVID pandemic for telehealth and telemedicine services. AMA CXO Todd Unger hosts.

The Current Procedural Terminology 2024 code, that is effective as of January 1, 2024, includes a new subsection containing three new codes related to caregiver training without the patient present. On today's episode we speak with AOTA's incoming Executive Director Katie Jordan about the changes and implications for billing and coding practices.  The 2024 AOTA Podcast episodes are sponsored by NYU Steinhardt's top-ranked Department of Occupational Therapy.

In this special Leap Year Day episode of Crush Medical Debt - Medical Bills Uncovered, Dr. Virgie reveals a rare expert insider look into why the old way of paying medical bills doesn't work anymore, how it's creating 100 million American healthcare cost vicitims and more every day, and what to do to protect you or someone you love from medical financial disaster. Show notes: To find a direct primary care practice (DPC), which gives you access to primary and preventive care for one low monthly subscription: dpcare.org/dpc-practice-locations. To find a federal qualified health center (FQHC) near you, which gives access to primary, dental and mental health care on a sliding scale based on your income: findahealthcenter.hrsa.gov. Correction: CPT is the abbreviation for Current Procedural Terminology.

In this special Leap Year Day episode of Crush Medical Debt - Medical Bills Uncovered, Dr. Virgie reveals a rare expert insider look into why the old way of paying medical bills doesn't work anymore, how it's creating 100 million American healthcare cost vicitims and more every day, and what to do to protect you or someone you love from medical financial disaster. Show notes: To find a direct primary care practice (DPC), which gives you access to primary and preventive care for one low monthly subscription: dpcare.org/dpc-practice-locations. To find a federal qualified health center (FQHC) near you, which gives access to primary, dental and mental health care on a sliding scale based on your income: findahealthcenter.hrsa.gov. Correction: CPT is the abbreviation for Current Procedural Terminology.

In this special Leap Year Day episode of Crush Medical Debt - Medical Bills Uncovered, Dr. Virgie reveals a rare expert insider look into why the old way of paying medical bills doesn't work anymore, how it's creating 100 million American healthcare cost vicitims and more every day, and what to do to protect you or someone you love from medical financial disaster. Show notes: To find a direct primary care practice (DPC), which gives you access to primary and preventive care for one low monthly subscription: dpcare.org/dpc-practice-locations. To find a federal qualified health center (FQHC) near you, which gives access to primary, dental and mental health care on a sliding scale based on your income: findahealthcenter.hrsa.gov. Correction: CPT is the abbreviation for Current Procedural Terminology.

Deborah Godes and Rachel Hollander join the Breakroom to provide an informative overview of CPT, why it matters to the world of health policy and what to expect at the upcoming CPT Editorial Panel meeting this week.

In part two of this series, doctors Chris Jagmin, MD, vice-chair of the CPT Editorial Panel and chair of the CPT Assistant Editorial Board along with Mark Synovec, MD, chair of the CPT Editorial Panel during the COVID-19 pandemic, continue their conversation about the influence of CPT in the health care system.  

What happens when a 50+ year-old terminology, with a long-standing, evidence-based, rigorous infrastructure, faces off against the stresses and challenges brought on by a pandemic and overnight shift in care delivery? In this episode, our guests Chris Jagmin, MD, vice-chair of the CPT Editorial Panel and chair of the CPT Assistant Editorial Board along with Mark Synovec, MD, chair of the CPT Editorial Panel during the COVID-19 pandemic, discuss the influence of CPT in the health care system.  

Effectively addressing health equity requires addressing CPT, the Language of Medicine, itself. CPT Editorial Panel member Barbara Levy, MD will share why diversity, equity and inclusion matters in CPT and how it supports optimal health of patients and populations.    

Current Procedural Terminology (CPT) codes play an important role in describing services and procedures performed by health care providers and ultimately in the payment for those services. This podcast reveals the role that APTA member volunteers play as advisors in the CPT and The Relative Value Scale Update Committee (RUC) process.

Current Procedural Terminology (CPT) codes play an important role in describing services and procedures performed by health care providers and ultimately in the payment for those services. This podcast reveals the role that APTA member volunteers play as advisors in the CPT and The Relative Value Scale Update Committee (RUC) process.

In this episode, Katie speaks with Jennifer who has been a medical coder and biller for the past 16 years. Jennifer offers up awesome tips and tricks for when you have to deal with insurance and fight to get your diabetes supplies covered. This one is super helpful! Enjoy!CPT codes: Stands for Current Procedural Terminology. A CPT code describes what type of care or service has been provided by a licensed medical provider. Each procedure is given its own unique 5 digit code that identifies to health insurance companies what type of care was provided. HCPCS codes: Stands for Healthcare Common Procedure Coding System and is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers.    Come find me on Instagram: @sugarmamaspodcastHave a question? An idea for a fantastic podcast episode? Want to be on the show?! Email me! sugarmamaspodcast@gmail.comSupport the show (https://www.buymeacoffee.com/sugarmama)

Dr. Louis McIntyre joins us this episode to discuss these insightful topics: -Accelerated recovery rate for patients with Cow Patch (Implant) -Hospital reimbursement rates have more than doubled in the past decade and hospital CEO pay increased 93%, while surgeon reimbursement has been flat -The reasons why private practice ortho groups should join MSO's View Dr. McIntyre's Editorial Commentary: A Rigged Game—Surgeon Reimbursement Under the Resource-Based Relative Value Scale, Current Procedural Terminology, and the Affordable Care Act in the The Journal of Arthroscopic and Related Surgery here. Thank you to our partner OrthoLazer for making this episode of The Ortho Show possible.

Drs Tucker, McIntyre, and Beach discuss A Rigged Game: Surgeon Reimbursement Under the Resource-Based Relative Value System, Current Procedural Terminology, and the Affordable Care Act.

Drs Tucker, McIntyre, and Beach discuss A Rigged Game: Surgeon Reimbursement Under the Resource-Based Relative Value System, Current Procedural Terminology, and the Affordable Care Act.

This week we're joined by Dr. Bill Weiss. Dr. Weiss is a clinical professor at the Texas Tech HSC at El Paso and the Paul Foster School of Medicine. Dr. Weiss specializes in sports medicine, arthroscopy, and foot and ankle surgery. This week we get into numerous topics including the dark side of health care administration, sports medicine, the Canadian healthcare system, and doing three fellowships. Like, subscribe, comment on the video. We're also on iTunes, Spotify, and any other podcast platform. Links to all of our episodes as well as our platforms can be found at www.orthotalkpod.com References from this episode: The dark side of the business of healthcare: McIntyre LF, Beach WS. A Rigged Game: Surgeon Reimbursement Under the Resource-Based Relative Value System, Current Procedural Terminology, and the Affordable Care Act [published online ahead of print, 2020 May 19]. Arthroscopy. 2020;S0749-8063(20)30423-0. doi:10.1016/j.arthro.2020.05.010 LaPrade MD, Camp CL, Brockmeier SF, Krych AJ, Werner BC. The Cost of Outpatient Arthroscopic Rotator Cuff Repairs: Hospital Reimbursement is on the Rise While Surgeon Payments Remain Unchanged [published online ahead of print, 2020 Apr 30]. Arthroscopy. 2020;S0749-8063(20)30315-7. doi:10.1016/j.arthro.2020.03.038 ACL graft options MOON Knee Group, Spindler KP, Huston LJ, et al. Anterior Cruciate Ligament Reconstruction in High School and College-Aged Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates?. Am J Sports Med. 2020;48(2):298-309. doi:10.1177/0363546519892991 Smith PA, Cook CS, Bley JA. All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger. Arthroscopy. 2020;36(6):1629-1646. doi:10.1016/j.arthro.2020.01.048

Almost 40% of Americans WITH health insurance reported they had received a surprise medical bill in the past year from a doctor or hospital for a service they thought was covered by their insurance plan. Why is this happening? And what can we do about it?  Please Support Congressional Dish – Quick Links Click here to contribute monthly or a lump sum via PayPal Click here to support Congressional Dish for each episode via Patreon Send Zelle payments to: Donation@congressionaldish.com Send Venmo payments to: @Jennifer-Briney Send Cash App payments to: $CongressionalDish or Donation@congressionaldish.com Use your bank's online bill pay function to mail contributions to: 5753 Hwy 85 North, Number 4576, Crestview, FL 32536 Please make checks payable to Congressional Dish Thank you for supporting truly independent media! Additional Reading Article: Went to the ER? You may be hit with a surprise medical bill by Tami Luhby, CNN, June 20, 2019. Press Release: House Supports Porter Amendment to Improve Affordable Care Act Enrollment by Representative Katie Porter, Porter House News, June 13, 2019. Article: Alexander-Murrary Bill, by Tammy Luhby, CNN, May 23, 2019. Bill: Bill S. 1531 Stopping The Outrageous Practice of Surprise Medical Bills Act of 2019 by Senator Bill Cassidy, Govtrack.us, May 16, 2019. Press Release: Trauma Coalition Press Release, by Trauma Association of America, May 16, 2019. Article: Trump calls for an end to surprise medical bills by Tami Luhby, CNN, May 9, 2019. Article: UnitedHealth's David Wichmann buys record $4.6 million worth of UNH stock by Alex Wittenberg, Biz Journals, May 7, 2019. Article: After Vox reporting, California moves forward on plan to end surprise ER bills by Sarah Kliff, Vox, April 24, 2019. Article: How to fight an outrageous medical bill, explained by Sarah Kliff, Vox, April 1, 2019 Bill: Bill S. 1266 Protecting Patients from Surprise Medical Bills Act 116th Congress, March 1, 2019. Bill: Bill H.R. 861 End Surprise Billing Act of 2019  116th Congress, January 30, 2019. Article: A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills by Sarah Kliff, Vox, January 24, 2019.  Article: After Vox story, Zuckerberg hospital rolls back  by Sarah Kliff, Vox, January 24, 2019. Document: NBER Working Paper No. 23623 Surprise! Out-of-Network Billing for Emergency Care in the United States by Zach Cooper, Fiona Scott Morton and Nathan Shekita, NBER, January 2019 Article: LifePoint merges with RCCH, goes private by Ayla Ellison, Becker Hospital Review, November 16, 2018. Article: “It’s unacceptable”: Sen. Maggie Hassan explains her plan to end surprise ER bills by Sarah Kliff, Vox, October 29, 2018. Article: Gov. Rick Scott took responsibility? No, he took $300 million | Randy Schultz by Randy Schultz, Sun Sentinel News, October 2, 2018. Article: UnitedHealthcare issues warning to hospitals about out-of-network coverage for ER physicians by Susan Morse, Healthcare Finance News, September 25, 2018. Article: Three Ways Self-Insured Plans Can Leverage State Laws to Protect their Members from Balance Billing  by Matthew Albright, The Self-Insurer, September 2018. Article: The Last Company You Would Expect Is Reinventing Health Benefits  by Reed Abelson, NY Times, August 31, 2018. Article: As Health and Financial Challenges Grow, More Older Adults File for Bankruptcy by Lindsey Copeland, Medicare Rights Center, August 9, 2018. Article: A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill by Jenny Gold, Kaiser Health News and Sarah Kliff, Vox, July 20, 2018. Article: Air Ambulances Are Flying More Patients Than Ever, and Leaving Massive Bills Behind  by  John Tozzi, Bloomberg News, June, 11 2018. Case Docket: Case Proceeding Air Medical Group, KKR North America, and AMR Holdco, In the Matter of Federal Trade Commission, May 3, 2018. Article: Are Physician Staffing Companies Killing the Patient Experience and Bottom Line? by Berta Bustamante, InsideArm, April 10, 2018. Press Release: Ambulance Companies Air Medical Group Holdings, Inc. and AMR Holdco, Inc. Agree to Divest Air Ambulance Services in Hawaii as a Condition of Merger  Federal Trade Commission, March 7, 2018. Document: Letter to Christopher Holden-President and Executive Officer for Envision Healthcare US Senate, September 20, 2017 Bill: California Assembly Bill 72 by Ann Whitehead,JD,RN.,CAP Physicians, August 30, 2017. Report: AIR AMBULANCE Data Collection and Transparency Needed to Enhance DOT Oversight  Government Accountability Office, July 2017. Article: The Company Behind Many Surprise Emergency Room Bills by Julie Creswell,Reed Abelson and Margot Sangor-Katz, NY Times, July 24, 2017. Article: AB 72: No More Balance Billing for Out-of-Network Care In-Network by Staff, Word&Brown, July 14, 2017. Report: Health Policy Report Up in the Air: Inadequate Regulation for Emergency Air Ambulance Transportation Consumer Reports, March 2017. Article: One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills by Christopher Garmon and Benjamin Chartock, Health Affairs, January 2017. Article: Trauma fees growing across the nation at 'absurd' rate by Alexander Zayas and Kris Hunley, Tampa Bay Times, November 21, 2014. Article: 10 Things to Know About HCA Becker's Hospital Review, April 16, 2014. Article: HCA to Eliminate Trauma Fees for Uninsured Patients Becker's Hospital Review, April 10, 2014.   Resources Profile Link: Connie Potter Profile, RN, BSN, MBA-HCA Link  Linkedin. Profile Link: Sherif Zaafran Profile, MD, FASA  Linkedin. Contact Us: Physicans for Fair Coverage  End of the Insurance Gap.org About Us: Independence Company (IBX)  IBX.com Document: License Agreement: Use of Current Procedural Terminology, Fourth Edition ("CPT®")  Centers for Medicare and Medicaid Services 2013-2018 Contributor List: Sen. Rick Scott Election Contributor List   Opensecrets.org Campaign Money Data Table: David Wichmann Political Campaign Contributions 2016 Election Cycle  Campaign Money.com Online Review Score: Regence Health Plan Company Profile Review  BestCompany.com False Claims Act: Nation’s Largest Healthcare Fraud Settlement Doesn’t Stop Medical Behemoth, WhistleBlowerJustice.net Visual Resources   Sound Clip Sources Hearing: NO MORE SURPRISES: PROTECTING PATIENTS FROM SURPRISE MEDICAL BILLS, Not on C-Span, Committee on Energy and Commerce, June 12, 2019. Watch on Youtube Witnesses: Sonji Wilkes: Patient Advocate Sherif Zaafran, MD: Chair of Physicians for Fair Coverage Rick Sherlock: President and CEO of Association of Air Medical Services James Gelfand: Senior Vice President of Health Policy at The ERISA Industry Committee Thomas Nickels: Executive Vice President of the American Hospital Association Jeanette Thornton: Senior Vice President of Product, Employer, and Commercial Policy at Americas’ Health Insurance Plans Claire McAndrew: Director of Campaigns and Partnerships at Families USA Vidor E. Friedman, MD: President of American College of Emergency Physicians Transcript 47:54 CEO Rick Sherlock: Emergency air medical services are highly effective medical interventions appropriate in cases where getting a patient directly to the closest most appropriate medical facility can make a significant difference in their survival in recovery. Today, because of air medical services, 90% of Americans can reach a level one or level two trauma center within an hour. However, since 2010, 90 hospitals have closed in rural areas and an estimated 20% more are at risk of closing. Our members fill the gap created by closures, but this lifeline is fraying as 31 air medical bases have also closed in 2019. 48:31 CEO Rick Sherlock: Emergency or medical providers never make the decision on who to transport. That decision is always made by a requesting physician or medically trained first responder. Air medical crews then respond within minutes, 24 hours a day, seven days a week without any knowledge of a patient’s ability to pay for their services. 48:45 CEO Rick Sherlock: Our members are unique in the healthcare system. The services heavily regulated by the states for the purposes of healthcare, as ambulances and the federal government for aviation safety and services as air carriers. It is their status as air carriers that allow rapid transport of patients over significant distances. Over 33% of our flights cross state lines every day. For that reason, the Airline Deregulation act uniform authority over the national airspace is essential to the provision of this lifesaving service. Exempting air medical services from the ADA would allow states to regulate aviation services, including where and when they’re able to fly, limiting access to healthcare for patients in crisis. 49:54 CEO Rick Sherlock: To prevent balance billing, our members are actively negotiating with insurance companies to secure in-network agreements. One member alone has increased their participation from 5% to almost 43% in the last three years. Despite that, some insurers have refused to discuss in-network agreements. That hurts both patients and caregivers. 50:30 CEO Rick Sherlock: Uh, covering air medical services in full, represents about a $1.70 of the average monthly premium. 51:50 CEO Rick Sherlock: $10,199 was the median cost of providing a helicopter transport. While Medicare paid $5,998, Medicaid paid $3,463 and the uninsured paid $354. This results in an ongoing imbalance between actual costs and government reimbursement and is the single biggest factor in increasing costs. 53:45 Senior VP James Gelfand: We’re focused on three scenarios in which patients end up with big bills they couldn’t see coming or avoid. Number one, a patient receives care at an in-network facility, but is treated by an out of network provider. Number two, a patient requires emergency care, but the provider’s facility or transportation are out of network. And number three, a patient is transferred or handed off without sufficient information or alternatives. It’s usually not the providers you’re planning to see. It’s anesthesiologists, radiologists, pathologists, or emergency providers or transport or an unexpected trip to the NICU. Many work for outsourced medical staffing firms that have adopted a scam strategy of staying out of networks, practicing at in-network facilities and surprise billing patients. It’s deeply concerning, but the problem is narrowly defined and therefore we can fix it. 54:40 Senior VP James Gelfand: The No Surprises Act nails it. It takes patients out of the middle and creates a market based benchmark rate to pay providers fairly. The benchmark is not developed by government and it is not price setting. The committee might also consider network matching. It’s simple. If a provider practices at an in-network facility, they take the in-network rate or they go work somewhere else. Or base the benchmark on Medicare, you could set the rate higher, say 125% of Medicare and still make the system more affordable, sustainable and simpler. These approaches will eliminate the surprise bills. That’s a huge win for patients. 54:50 ** Senior VP James Gelfand: But not everyone wants to stop the surprise bills. Some provider specialties are saying, “let us keep doing what we’re doing, just use binding arbitration to make someone else pay these bills”. They’re asking for a non- transparent process that could force plans and employers to pay massive and fake medical list prices. It’s essentially setting money on fire. Funds that would have been used to pay for healthcare will instead be spent on administrative costs such as lawyers, arbitrators, facility fees, and on reasonable settlement amounts. Make no mistake, patients will pay these costs. 55:20 Senior VP James Gelfand: The ground and air ambulance companies are asking Congress to let them keep surprise billing too. Do nothing, wait for another study, another report, and there have already been four. They know patients cannot shop for them and many participate in no networks. State insurance commissioners are begging for help with air ambulances, but Congress has tied their hands. Employers think Congress should end this. Treat medical transport the same as emergency care. We should end surprise billing in the ER and on the way there. 56:30 Senior VP James Gelfand: Other providers figure they’re willing to stop surprise billing, but only if they can increase in-network rates. They’re calling for network adequacy rules to force insurers and employers to add more providers to their networks, even if those providers demand astronomical payments. Does anyone here actually believe that these hospital based doctors who services cannot be shopped for, who are guaranteed to see our patients, are begging to be included in our networks, but nobody will return their calls? That they have no choice but to go and join these out of network Wall Street owned firms? It doesn’t make sense. 57:00 Senior VP James Gelfand: Employers design health benefits to help our beneficiaries. We don’t sell insurance. We want networks that meet our patients’ needs. Why would we want to cover an operation, but leave out the anesthesia? We want our employees to be able to afford their health insurance too, and that means we must be able to say no when providers are gaming the system. 1:08:10 Dr. Vidor Friedman: Unlike most physicians, emergency physicians are prohibited by federal law from discussing with a patient any potential costs of care or insurance details until they are screened and stabilized. This important patient protection known as Emtala, ensures physicians focus on the immediate medical needs of patients. However, it also means that patients cannot fully understand the potential cost of their care or the limitations of their insurance coverage until they receive the bill. 1:10:40 Dr. Vidor Friedman: The goal should be a system in which everyone is in-network, or essentially that. That requires a level playing field between providers and insurers. Insurers are concerned that benchmarking the even median charges, favors providers. Providers are concerned that benchmarking the median in-network rates, favors insurer’s. What’s Congress to do? ACEP supports a system that has already proven to be balanced between insurers and providers. That is a baseball style independent dispute resolution process similar to that used in New York and noted in the legislative proposal put forth by Doctors, Ruiz Rowe and Busan. 2:02:30 Rep. Brett Guthrie: If there does become a federal arbitration system, what do you think congressional oversight should be? And I don’t know if that should be something that I’m supposed to talk about or…Sonji Wilkes: Well, I’ve been sitting here listening, thinking I pay my insurance premiums, I do my part and I expect the bill to be paid. I mean, there’s only so much I can do to control that and I don’t really care how the reimbursement works. And quite frankly, I think the insurance industry is doing probably better in their bottom line than my bottom line. Um, I want to go to the best provider possible and I want the best care possible. I don’t really care how the payment works. 2:34:50 Dr. Sherif Zaafran: Well, I can tell you that from the physician’s standpoint, for emergency room physicians for example; the average weighted cost of every visit is about $155. 3:49:00 CEO Rick Sherlock: The median cost of a helicopter air transport is $10,199 according to a study conducted in 2017. If you look at the cost of uncompensated care, because Medicare pays less than $.60 on the dollar of that 10,199. About $5,998, Medicaid pays significantly less than that. Less than $3,500 on average, and the uninsured pay about $350. Those make up…those three groups make up 70% of air medical transports. So when you take that cost of uncompensated care and you add it to the median cost of $10,200, that’s the average charge of $36,000 that the representative from New Mexico referenced earlier. When you…when those kinds of situations happen, no one in our industry wants to see a patient or their family placed in jeopardy because they’ve just had a health emergency. Our members will sit down with each individual and their families and work out a solution tailored for them. 3:54:30 Dr. Sherif Zaafran: Again, there is no such thing as an out of network provider. There is a provider who may happen to be out of network with that specific product. So the only one who knows what the product is, is of course the patient and the insurance carrier and they’re the only ones who really have the information as to whether they’re in-network or out of network. Hearing: The Need to Reauthorize the September 11th Victim Compensation Fund, June 11, 2019 Hearing: Hearing on September 11 Victims Compensation Fund, June 11, 2019 Hearing: Watch on CSPAN-Surprise Medical Bills House Ways and Means Subcommittee on Health-May 21, 2019 Committee website Watch on YouTube Witnesses: Rep. Katie Porter (CA) James Patrick Gelfand: Senior Vice President, Health Policy, ERISA Industry Committee Dr. Bobby Mukkamala: Board of Trustees, American Medical Association Tom Nickels: Executive Vice President, Government Relations and Public Policy, American Hospital Association Jeannette Thornton: Senior Vice President for Product, Employer, and Commercial Policy at America’s Health Insurance Plans (AHIP) Transcript *7:15 Chairman Lloyd Doggett (TX): Fortunately, there now appears to be a growing consensus. Most recently joined by president Trump that holding the patient harmless should form the foundation for any surprise billing proposal. Under the legislation that I advanced, patients would only be charged in network cost sharing rates in emergency situations and non-emergency situations out of network charges would be permitted only when the patient has agreed in advance after receiving effective notice regarding any providers and services together with estimated charges. No other bill addressing this issue has yet been filed here in the house, but there is a very useful discussion draft proposal that is being circulated on a bipartisan basis by the House Energy and Commerce Committee and there’s several proposals that have service in the Senate. While every proposal currently begins with the basic premise of the enterprise billing act, conflict remains over how to resolve insurer provider disputes. *13:40 Rep. Katie Porter (CA): I’m concerned about surprise billing, as someone who’s dedicated my life to protecting consumers, but also because I have had to fight my own battle with surprise billing. On August 3rd last year when I was on the campaign trail, I started to feel pain in my abdomen. At 1:00 PM I could not continue and I went home. At 4:31, I texted my campaign manager that I needed to go to the emergency room. I couldn’t safely drive through the pain and I remember sitting on my front porch, so if I lost consciousness, somebody might find me and I wouldn’t be home alone. I didn’t call an ambulance because I was concerned about the cost. I could not drive and I asked my manager to please take me to Hoag hospital. I chose that hospital even though it was farther away from other providers, because I knew Hoag was an in-network facility. When I got to the hospital, I waited six hours alone in the emergency exam room without treatment. When I finally went to surgery, my doctor told me it was nothing to worry about, just a routine appendectomy. I was given anesthesia and when I awoke, the team around me was panicking. They couldn’t get my temperature to drop and they couldn’t get my blood pressure to rise. My appendix had ruptured hours before causing an infection that was making my whole body very sick. I spent the next five days in the hospital receiving powerful IV antibiotics. A few weeks later, I received the bill from my insurance company. The idea of an astronomical hospital bill had weighed heavily on me and I was happy to see that the cost of my emergency room treatment and assessment and hospital charges, and nearly all of my inpatient services, were covered. I remember sitting at my kitchen table and taking a deep breath filled with relief, but a few days later I received another bill. This one from my surgeon. While the hospital I had gone to was in-network, the insurance company now claimed the surgeon was not, even though they had sent me a notification telling me that my surgeon was in-network . Enclosed in that bill for nearly $3,000, was a handout from my surgeon detailing the steps I would have to take while recovering in order to fight to have my insurance company cover the care. So many of his patients had been put in this situation, that this medical doctor had used his staff to address patient billing problems. That’s not what he trained for in medical school. Your so-called explanation of benefits and the surgeon’s handout explained that he was being treated as an out of network provider even though he was employed by and worked at an in-network hospital. As someone in an emergency situation, I had no ability to assess whether he was in or out of network, and in those cases insurers are supposed to cover the costs, but I got that bill because my insurer put profits before patients. I called insurance company to request an appeal. The benefits manager kept asking me questions to guide me and coach me towards saying that it was my surgeon’s fault to blame him for overcharging me. She asked me to call the surgeon and attack my doctor for his bill. Apparently, to Anthem Blue Cross, $3,000 was too high a price for saving my life. The tens of thousands in premiums I’d paid to that company over the years were not enough to have them, cause them to cover the lifesaving care. Nearly five months after I was hospitalized, the surgeon simply requested payment, and at that point I reached out to my employer of the University of California Irvine. That’s when I learned that U.C. Irvine has a designated patient advocate, a medical doctor, whose sole job is to help university employees get the health insurance that the university and the employees pay for. Can we just reflect on that for a moment? The university is paying a medical doctor to do nothing but navigate insurance. Finally, the patient advocate, invoking the fact that I had just been just elected to Congress, was able to get the insurance company to agree to pay my surgeon’s bill. But here’s what I learned from getting sick. I am well educated. I had an employer prepared to help me. I have professional experience fighting for consumer rights, but there are thousands of Americans with fewer resources than me who are surprised with bills far more devastating than mine. I’m here today because they refuse to accept this as the status quo. I refuse to stand idly by while families go bankrupt because of surprise medical bills. Any solution to this issue must rely, must not rely, excuse me, on the patient’s ability to go to war with the insurer or with their provider. That is not the solution. It’s time we start putting patients first. 31:00 Jeanette Thornton: We ask that federal legislation focus on four things. First, balanced billing should be banned in situations where inpatients are involuntarily treated by an out of network provider. This includes emergency health services at any hospital, any health healthcare services or treatment performed at an in-network facility by an out of network provider, not selected by the patient and ambulance transportation in an emergency. Second, health insurance providers should be required to reimburse out of network providers inappropriate and reasonable amount in those above scenarios. Third, state should be required to establish an independent dispute resolution process that works in tandem with the established benchmark. Fourth hospitals or other healthcare providers should be required to provide advanced notice to patients of the network status of the treating providers. We appreciate the health sub-committee chairman Lloyd Doggett has introduced legislation to end surprise billing act or HR 861, which would establish a role for hospitals in providing such notices, along with banning balanced billing. AHIP supports this bill. 46:00 Chairman Lloyd Doggett (TX): What I’m referring to is the difference… Dr. Bobby Mukkamala: Right. Chairman Lloyd Doggett (TX): …in charges and why one one price for those who are in network and another for those that are out. Dr. Bobby Mukkamala: Right. So there is a benefit for me to be in network with Blue Cross Blue Shield of Michigan for example. I get something from that. They sit with me, they show me their data. We had…we worked together on incentive programs to sort of curb costs. If there’s an insurance company that’s in town that does none of that activity to improve the care of the population in my town, but yet wants to benefit from the same rate of compensation to me, they’re doing nothing to earn that discount. Blue Cross sits across from me on a weekly or monthly basis to improve the care of my population. But Golden Rule insurance, that’s new in town for example, doesn’t do any of that work and yet wants to benefit from having the same provider rates. No, I mean, I take a discounted rate from Blue Cross because of all this other robust activity. But if you’re not offering me anything to participate in your network, then naturally, you should be expected to pay more for my services. Right? I get something from Blue Cross. I get nothing from Golden Rule. 53:05 Dr. Bobby Mukkamala: Medicare is usually sort of the foundation upon which all the other insurance companies tend to set their rates. So when I participate in network, like with Blue Cross Blue Shield of Michigan, it’s usually about 110/ 115% of Medicare rates. So that’s one step higher. If I don’t participate with Blue Cross Blue Shield of Michigan, then that rate is so I can get the assigned rate from them and then I have a choice about what to do with the balance. And usually in my practice, I write that off. I don’t balance bill the patient. Uh, but Blue Cross Blue Shield sort of sets their rate and that’s it. My point is that, if-in Blue Cross Blue Shield, I have a great relationship with, we do a lot of constructive work together. But if a new insurance company comes into town and puts up billboards and markets their product and says, here, come, come buy our policy, and then they get 15,000 patients to sign up, but has never come to my door to say, you know, when they have an ear, nose and throat problem, we’d like you to be in-network and provide their care. Why should they get the benefit of the in-network price that Blue Cross Blue Shield gets? So, my point, is that that out of network price for this new insurance company that wants me to take care of their patient, but never came to sit down with me to sign a contract, ought to be something that I negotiate with them, not something that’s dictated to me. 55:50 Rep. Mike Thompson (CA): A staff person of mine went to the emergency room. He has insurance. His insurance covered nearly everything, including a cat scan. But a few weeks later, he got two separate bills from physicians he never saw and didn’t ask to see. They reviewed some of his test results and the bill for those two physicians was larger than the bill for his total ER visit. 56:15 Rep. Mike Thompson (CA): It’s also alarming that, uh, according to one study, 20% of hospital visits, one of every five of those visits, uh, that began in the ER, resulted in a surprise bill. 58:30 Dr. Bobby Mukkamala: Uh, yes, sir. So, in answer to your question, there are multiple already cases documented of insurance companies shrinking their network in California because they can get the same service at that rate with physicians that are out of their network. And so, contracts are already not being renewed for physicians that have had contracts for 20 years, and then they go to renew it and they’re dropped from the network. 1:03:00 Dr. Bobby Mukkamala: My wife and I, we contract with probably about 30 insurance companies. When I take a kid’s tonsils out, one insurance company may be $200- may pay me $200, one pays me about $450 and everything in between. I can’t have a different fee in my fee schedule for each of those. So my fee for tonsillectomy is about $475, so that when I do it, I know that the highest paying payer, I’m still-they’re still within that threshold, right? Because if I charge $400, they’re not going to send me $450. They’re going to send me $400. 1:07:00 Jeanette Thornton: So it’s very interesting what we’ve seen and when it comes from a hospital perspective. It’s maybe only 15% of the hospitals nationwide that are causing this issue that results in, you know, 80% of the visits. One of the statistics had cited a lot that result in a surprise medical bill. So this is not every doctor. This is not every hospital that are resulting in these surprise medical bills. It’s really more of a targeted problem. 1:09:15 Tom Nickels: In terms of how much of this is really going on, I think there is a certain level of frustration. I don’t know that we all know with certainty. The only federal study that I’ve seen, that we’ve seen, is from the Federal Trade Commission, which basically said that they studied ambulances going to hospital emergency departments. 99% of hospital emergency departments in that study were in-network. So it’s not the hospital itself that is out of network. it is people, physicians who practice in our institution. 1:22:20 Tom Nickels: The federal government-state government need to acknowledge that they underpay. I mean, Medpack and others acknowledges that this isn’t just industries talking about ourselves. AMA has said the same thing on the physician side, but I think that the federal government and state governments have a responsibility to pay more adequately. The truth of the matter is, and we haven’t even talked about this, is the cost shift is that private insurers pay more than costs and the government pays less. That should end. The government should take responsibility. 1:38:00 Tom Nickels: We cannot force by law, physicians who are not employed by us to take in-network rates. That is-if we did that, um, we would be sued. It would be restraint of trade. Um, however, what we’re trying to suggest here and I think what the other panelists are trying to suggest, is we have a way to protect the patient from that surprise bill. To your question about who are these physicians that you don’t even know about who are treating you, if you come in in an emergency, you don’t know what’s going on. And you need to be taking care of it, who’s ever there is going to take care of you. The other situation which we’ve talked about is when you knowingly come into an inpatient in-network facility. You did all the right things, but an out of network physician, (anesthesiologists, perhaps radiologists, pathologists) takes care of you. And that’s where the, uh, the bill is generated from. So we cannot make people do that. We try to get physicians to be in our networks-in the same networks. But again, this is an issue of private contracting. 1:42:05 Rep. Mike Kelly (PA): I do agree with you. If there’s limited talent there to take care of that specific problem, there has to be a way of compensating for it. Because at the end of the day, it is a business. Dr. Bobby Mukkamala: Right. So the solution is if an insurance company is going to come into Flint, Michigan and sell insurance, they know that eventually they’re going to need a hand surgeon, right? How do they sell insurance to a town that’s an industrial based town, where there’s a lot of hand injuries and not have any hand surgeons in their network? When they put up the billboard saying, “we’re selling insurance here”, they should have at the same time look at their provider list and say, “you know what”?, we’re missing an orthopedic hand surgeon. "Let’s go find one and figure out how to get him in-network or get her in-network. Right? And that’s a step that’s skipped routinely, right? They’ll sell the product for years and then fill in this way with lack of a good provider network by trying to negotiate out of network rates that are the same as in-network because they’d skip that first step, right? Maintain a network adequacy-establish a network adequacy before you sell your product. 1:48:30 James Gelfand: Many of the hospitals are not doing what Zuckerberg hospital was doing. The hospital will be in-network, but they will have outsourced their emergency room to a Wall Street owned private company and that company won’t take insurance. And those guys are definitely making enough profits that Wall Street is suggesting that people should invest in those companies because of these relationships they have with the in-network hospitals and the out of network emergency rooms. Trump remarks on medical billing-Watch on C-SPAN, May 9, 2019 13:00 President Donald Trump: Today I’m announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing. And these senators and congressmen and women that are with us today are really leading the charge. And I appreciate that they’re all here. Thank you all. Thank you all for being here. This is fantastic. And I think it’s going to be a successful charge. From what I understand, we have bipartisan support, which is rather shocking. That means it’s very important. That means it’s very good. But that’s great. First, in emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. So-called balance billing should be prohibited for emergency care. Pretty simple. Second, when patients receive scheduled, non-emergency care, they should be given a clear and honest bill upfront. That means they must be given prices for all services and out-of-pocket payments for which they will be responsible. This will not just protect Americans from surprise charges; it will empower them to choose the best option at the lowest possible price. Third, patients should not receive surprise bills from out-of-network providers that they did not choose themselves. Very unfair. Fourth, legislation should protect patients without increasing federal healthcare expenditures. Additionally, any legislation should lead to greater competition, more choice — very important — and more healthcare freedom. We want patients to be in charge and in total control. And finally, in an effort to address surprise billing, what we do is, all kinds of health insurance — large groups, small group, individual markets, everything. We want everything included. No one in America should be bankrupted and unexpectedly by healthcare costs that are absolutely out of control. No family should be blindsided by outrageous medical bills. And we’ve gone a long way to stop that. Examining Surprise Billing: Protecting Patients from Financial Pain-Not on C-SPAN, House Committee on Education and Labor, April 2, 2019 Watch on YouTube Witnesses: Christen Linke Young: Fellow at USC-Brookings Schaeffer Initiative on Health Policy Ilyse Schuman: Senior Vice President for Health Policy at American Benefits Council Frederick Isasi, Executive Director at Families USA Professor Jack Hoadley: Research Professor Emeritus at Georgetown University’s Health Policy Institute Transcript 7:15 Chairman Frederica Wilson (FL): This is the first hearing the United States Congress has held on surprise billing. 7:30 Chairman Frederica Wilson (FL): Surprise medical bills occur when patients covered by health insurance are subject to higher than expected out of pocket costs for care, received from a provider who is outside of their plan’s network. The victims of surprised medical billing often have no control over whether they’re medical provider is in or out of network. 8:15 Chairman Frederica Wilson (FL): A young San Francisco woman named Nina Dang suffered a severe bike accident. She was barely lucid when a bystander called an ambulance and took her to an emergency room at a nearby hospital. Before she knew it, doctors had done x-rays and scans and put her broken arm in a splint and then sent her on her way. A few months later, Nina was hit with a $20,000 medical bill because the hospital, which she did not choose, was an out of network facility. 8:30 Chairman Frederica Wilson (FL): But even patients who are able to take precautions to avoid out of network costs during a medical emergency, are not immune from surprise bills. Scott Cohan suffered a violent attack one night in Austin, Texas. He woke up in an emergency room with a broken jaw, a throbbing headache, and staples in his head. Despite his shock and immense pain, Scott took out his phone and searched through his insurer’s website to make sure he was laying in an in-network hospital bed. When he found out it was, he proceeded with unnecessary jaw surgery. Imagine Scott’s frustration and devastation when he received a surprise medical bill for nearly $8,000. It turned out that the emergency room was in his insurance network, but the oral surgeon who worked in the ER was not. 16:00 Rep. Tim Walberg (MI): 39% of insured working age adults reported they had received a surprise medical bill in the past year from a doctor, hospital, or lab that they thought was covered by their insurance. Of the 39% of individuals who received surprise medical bills, 50% owed more than $500. 27:05 Ilyse Schuman: While a number of states have sought to address this problem or risk that exempts self insured plans from State Insurance Regulations to ensure that national employers can offer uniform health benefits to employees residing in different states. Accordingly, the problem of surprise billing cannot be left to the states to solve. 33:20 Frederick Isasi: So what’s most important to remember about this issue? We are talking about situations in which families, despite enrolling in health insurance, paying their premiums, doing their homework and trying to work within the system, are being left with completely unanticipated and sometimes financially devastating healthcare bills. And this is happening in part, and I want to say this really clearly because hospitals, doctors and insurers are washing their hands of their patient’s interest. 33:50 Frederick Isasi: Take for example, one significant driver of this problem. The movement of hospitals to offload sapping requirements for their emergency departments to third party management companies. These hospitals very often make no requirements of these companies to ensure the staffing of the ED fit within the insurance networks that the hospitals have agreed to. As a result, a patient who does their homework ahead of time and rightly thinks they’re going to an in network hospital, received services from an out of network physician and a surprise medical bill follows. 34:20 Frederick Isasi: Let me give you one real world example. Nicole Briggs from Morrison, Colorado outside of Denver. Nicole woke up in the middle of the night with intense stomach pain. She went to a freestanding ER. She was told she needed an emergency appendectomy. She went to a local hospital. She did her due diligence. Confirmed repeatedly that the hospital and its providers were in network. However, months later she received a surprise bill from the surgeon who ended up, was out of network. The bill to Nicole was $5,000. Nicole tried to work it out with her insurance company, but within two years, a collection agency representing the surgeon took her to court and won the full amount, including interest. As a result, a lien was placed on her home and the collection agency garnished her wages each month. This came right before Nicole was about to deliver a baby and go on maternity leave. And by the way, this investigation found that there were over 170 liens placed on people’s homes in the Denver area by emergency department physicians. 38:05 Professor Jack Hoadley: Our research shows that today, 25 states have acted to protect consumers from surprise bills in at least some circumstances. Nine of these 25 meet our standards as offering what we consider to be comprehensive protection. For protections to be comprehensive, we look to number one, whether they apply in both emergency situations and an in-network hospital setting, such as electing an in-network surgeon, but being treated by another clinician who’s out of network. Second, that these laws apply to both HMO’s, PPO’s and all other types of insurance. Third, that the law does address both insurers by requiring them to hold consumer’s harmless from balanced bills and providers by barring them from sending balanced bills. And fourth, that the laws adopt some kind of a payment standard. Uh, either a rule to determine payment from insurance provider or an arbitration process to resolve payment disputes. Although these four conditions don’t guarantee complete protection for consumers, they combine to protect consumers in most emergency and network hospital settings that the states can address. But as you’ve already heard, state protections are limited by federal law, ERISA, which exempt states from state regulation’s, self insured, employer sponsored plans. 43:30 Chairman Frederica Wilson (FL): Under current law, who is responsible for making sure that a doctor or a hospital is in-network? Is it the doctor, the insurance company or the patient themselves? Frederick Isasi: Uh, chairman Wilson, thank you for the question. To be very clear, it is the patient themselves that has a responsibility and these negotiations are very complex. These are some of the most important and intense negotiations in the healthcare sector between a payer and a provider. There is absolutely no visibility for a consumer to understand what’s going on there. And so the notion that a consumer would walk into an emergency department and know, for example, that their doctor was out of network because that hospital could not reach agreement on an in-network provider for the ED is absurd, right? There’s no way they would ever know that. And similarly, if you walk in and you received surgery and it turns out your anesthesiologist isn’t in-network, there’s no way for the consumer to know that. Um, and I would like to say there’s some discussion about transparency and creating, you know, sort of provider directories. We’ve tried to do that in many instances. And what we know is that right now the healthcare sector has no real way to provide real actual insight to consumers about who’s in-network, and who’s out of network. I would-probably everybody in this room has tried at some point to figure out if a doctor’s in-network and out of network and as we know that system doesn’t work. So this idea that consumers can do research and find out what’s happened behind the scenes in these very intensive negotiations is absurd and it doesn’t work. 46:30 Professor Jack Hoadley: Provider directories can be notoriously inaccurate. One of the things that, even if they are accurate, that I’ve seen in my own family is you may be enrolled in Blue Cross-You ask your physician, "are they participating in Blue Cross? They say “yes”, but it turns out Blue Cross has a variety of different networks. This would be true of any insurance company, and so you know, you may be in this one particular flavor of the Blue Cross plan and your provider may not participate in that particular network. 47:30 Christen Linke Young: Notice isn’t enough here. Even if a consumer had perfect information, which is not a reasonable expectation, but even if they did have perfect information, they can’t do anything with that information. They can’t go across town to get their anesthesia and then come back to the hospital. Um, their-even with perfect information, they may be treated by out of network providers. And so we need to set a standard that limits how much providers can be paid in these out of network scenarios that makes it sort of less attractive for providers to remain out of network. And so instead, they are subject to more normal market conditions. 1:01:25 Rep. Phil Roe (TN): I’ve had my name in networks that I wasn’t in. That you-that you use, and many of those unscrupulous networks, will use that too to get people to sign up because this doctor, my doctor is in there when you’re really not. 1:10:25 Frederick Isasi: Um, there is a concept here, which is, what does in network mean, right? When you sit down with your husband or your partner and decide what kind of insurance do we want for our kids, right? We want to make sure that they can go to the ED if they’re playing soccer, they get hurt, all those sorts of things. The question is when you make that decision and you say, "Oh, look, this hospital is in-network, right? But what does that mean? If you can go to that hospital and all the services they’re providing are out of network, right? And I think as you’ve said, and as we’ve heard from other folks, the patient is not the person who should be responsible for that. It’s the folks who are negotiating. It’s the hospital, it’s the doc’s and the payers that should bear that responsibility. So let’s start by clarifying what does in-network mean, so that we have some way of making educated decisions about the insurance that we’re purchasing and putting our trust in. 1:29:30 Professor Jack Hoadley: There may be instances where consumers get bills sent to them, aren’t aware that they don’t need to pay them, so don’t start the process. And that goes to this sort of point of how do you really make sure it’s not the consumer’s responsibility to figure out that, oh, I don’t, by law, I don’t actually have to pay this bill. Now what do I do to make sure that happens? If you don’t know that, uh, that doesn’t really help you. And so what some other states like California has done, is to include a provision that says the provider really can’t send a bill and if they do end up sending a bill and the consumer pays it, there’s an obligation on that provider to refund the amount that was paid back to the consumer. And that’s something we haven’t seen in some of the other states. 1:39:15 Rep. Joe Courtney (CT): ERISA really has to be dealt with if we’re going to really have a comprehensive solution for America’s patients. Is that correct? Ilyse Schuman: That’s exactly right. Um, for the self funded plan too 60% of employer based plans that are not subject to these state laws, like in Connecticut or other states, we have to have a federal solution that addresses ERISA, so that we deal with this problem in a uniform nationwide way. Documentary: This is a clip from the documentary: 911, Toxic Legacy which aired on Canadian CBC 9/10.2006, September 10, 2006 Community Suggestions See Community Suggestions HERE. Cover Art Design by Only Child Imaginations Music Presented in This Episode Intro & Exit: Tired of Being Lied To by David Ippolito (found on Music Alley by mevio)

Changing of the Codes; ICD-10 and CPT Codes   Welcome to Billing Buddies YouTube and Podcast series.  In this episode, we will be discussing the annual changing of the codes; particularly, the ICD-10 and CPT codes. Healthcare professionals, medical billers and payers rely on several types of codes sets in order to communicate pertinent information about patients.  These code sets include TOS (Type of Service); POS (Place of Service), and NPI (National Provider Identifier) to name a few.  In this writing, I will address the codes that are updated annually, the ICD-10 and CPT Codes. The ICD-10 codes are specifically called either ICD-10 CM or ICD-10 PCS.  The ICD-10 CM codes are used for all healthcare settings except hospital inpatient settings where ICD-10 PCS codes are used.  For the purposes of this writing, I will be referring to ICD-10 CM codes and abbreviate them to ICD-10.  Each year on October 1st, the ICD-10 codes have revisions, additions and deletions.  These codes are copyrighted and maintained by the World Health Organization.  The ICD-10 codes define the diagnosis of the patient.   There are many free resources online for healthcare professionals and billers to find the updated codes.  One of my favorite sites is the www.icd10data.com.   On this site, you can see the added, deleted and revised codes.   Codes with red arrows next to them signify codes that are non-billable/non-specific codes.  These codes cannot be used for billing purposes.  Codes with green arrows next to them signify codes that are billable codes.  It is important to note that diagnosis codes should be coded to the highest specificity.  Besides free online resources, ICD-10 coding books may also be purchased from several publishers. CPT codes are copyrighted and maintained by the AMA.  CPT is the acronym for Current Procedural Terminology.  The CPT codes define the services and procedures received by patients.  Each year on January 1st, the CPT codes have revisions, additions and deletions.   The CPT coding updates need to be purchased either in books or an online subscription.   Many of the CPT codes are addressed in payer policies and can be read for free online, but for a complete resource, it is best to purchase an updated manual or online subscription. It's important to note that HIPAA defined which codes sets are used to communicate.  Prior to HIPAA, many payers defined their own codes sets.  For example, in some specialties, like chiropractic, codes varied by payer.  Medicare, worker’s compensation and commercial insurance each had their own code sets.  HIPAA streamlined the coding processes by defining one code set for each data element. In summary, whether you use online resources or purchase manuals, it is important to note that ICD-10 codes update each year on October 1st and CPT codes update each year on January 1st.  You want to stay updated to the most current codes to be compliant with your coding and billing and to reduce denials from payers. This was brought to you by Billing Buddies.  Billing Buddies is a medical billing and consulting service established in 1994.  We offer services to a variety of specialties across the United States.  For more information, please call or text 612.432.2366.  Thank you for listening to Billing Buddies YouTube and Podcast Series and remember to “Buddy Up with the Best”, Billing Buddies.   Have a great day!

On this Episode of the ASC Podcast with John Goehle we check in on the latest news in the ASC industry and discuss the biggest news this last week - the final 2019 CMS Changes to ASC Payment Systems and Quality Reporting Programs.  Note that throughout this episode we will be discussing various CPT-4 Codes. CPT, better known as the Current Procedural Terminology is a copyright of the American Medical Association and all rights are reserved.

On this episode of the ASC Podcast with John Goehle we discuss the latest news and continue our discussion of the 2019 Proposed Changes to ASC Payment Systems and Quality Reporting Programs.  Note that throughout this episode we will be discussing various CPT-4 Codes. CPT, better known as the Current Procedural Terminology is a copyright of the American Medical Association and all rights are reserved by the AMA.

On this special episode of the ASC Podcast with John Goehle we discuss the 2019 Proposed Changes to ASC Payment Systems and Quality Reporting Programs.  CMS published the proposed rule this last week and there are SIGNIFICANT ramifications for the ASC industry as well as some good and bad news about payment rates, depending on your specialties.  With this episode, we will begin the discussion of the new regulations, and their impact on the ASC Industry. Note that throughout this episode we will be discussing various CPT-4 Codes. CPT, better known as the Current Procedural Terminology is a copyright of the American Medical Association and all rights are reserved.

US physicians nearly universally use the CPT coding system. This code set communicates medical, procedural, surgical and diagnostic services and is a critical component of describing the work we do.Drs. Josh Hirsch, Jackie Bello and Raymond Tu are actively involved in the world of physician reimbursement through their associations with the Relative-Value Update Committee (RUC) and Current Procedural Terminology (CPT) committees. In this podcast they discuss the role CPT plays in physician reimbursement and its interplay with the RUC and Centers for Medicare & Medicaid Services (CMS). The JNIS article being discussed is:Current procedural terminology; a primer http://goo.gl/TIhC8NListen to Dr Hirsch's previous podcast on component coding and the RUC: http://goo.gl/KcEbk4