Podcasts about Medicare

Mat Staver is the founder - chairman of Liberty Counsel. Mat is a constitutional attorney with three landmark cases before the U.S. Supreme Court.--This morning a landmark decision was handed down from the Supreme Court. With Justice Alito writing the majority opinion and joined by Thomas, Gorsuch, Kavanaugh and Barrett, the court overturned Roe v. Wade as well as the 1992 Planned Parenthood of Southeastern Pennsylvania v. Robert P. Casey decision.--In less than 60 minutes following the court's decision, Missouri, which had a -trigger law- on the books, put its ban on abortion into effect as Attorney General Eric Schmidt, signed such a statement. --Others states have laws on the books that were never repealed when Roe went into effect. So while these laws in those states were put on -temporary- hiatus by Roe, since they were never removed from the books, those are coming back into play due to today's repealing of Roe. --Mat explained that there are those who want to pass federal legislation that would impose abortion on the states and he also believes we'll see crazy things from the Biden administration to try and force states to include abortion whether it's through Medicaid or Medicare. Then there's also the battle at the state level.--This single news story has many aspects to pay attention to. Mat explained these aspects.

Inflation, the markets and rising interest rates have people concerned about their finances. In this episode we tackle the problems and possible solutions to help you with your finances and retirement income.

The perfect storm... Rising inflation, rising interest rates and a bear market. In this episode we talk about what's happening and what you can do to weather the storm.

(00:00) Intro(02:57) Introducing Shaun Maguire(09:52) DARPA to cyber security(15:41) Paying in Bitcoin(17:27) Wife's family fleeing their country for safety(27:27) Crypto in autocratic nations(31:20) Middlemen(35:30) Investing in equity(36:28) Blockchain video games(37:36) Uniswap(40:33) Future use cases(42:56) Following where young people are excited(49:27) Introducing Andrew Parker(51:15) How Logan and Andrew met(55:12) Andrew's background(57:30) Telehealth – MD Live(58:52) The idea for Papa(1:02:19) State of health insurance(1:04:12) Pals(1:07:17) Papa members(1:11:54) Size of Papa(1:13:40) Justifying Papa to health plans(1:16:41) Impacting outcomes(1:19:23) Market of Medicare vs Medicare Advantage(1:21:49) Family care(1:24:07) Employer healthcare plans(1:29:00) Fundraising(1:35:31) Miami tech(1:38:27) Papa.com(1:42:13) Closing 

On this episode of The Ty Brady Way, Ty is joined by guest Stephanie Heusser. Stephanie shares how she got involved in the Medicare world and how it's changed her and her family's life. Stephanie speaks about how her husband helped train her for the test and her first few appointment after getting her license.   Stephanie speaks about how a career change for her husband upturned their world for the better but how they had to work through some hard changes and how it brought their family together. Stephanie shares her advice to stay at home moms who are looking for something to do but can't go and get a full time high paying job.   Stephanie and Ty discuss how impactful doing this job is and how rewarding it is getting to help people every single day. Stephanie shares how she could never go back to a 9-5 after this job as it's just so much more rewarding and worth it compared to a 9-5 where you're killing yourself working and getting very little in return for your efforts.     As always, we would like to hear from you! Email us at thetybradyway@gmail.com Or DM us on Instagram @thetybradyway https://www.instagram.com/thetybradyway/

Mat Staver is the founder - chairman of Liberty Counsel. Mat is a constitutional attorney with three landmark cases before the U.S. Supreme Court.--This morning a landmark decision was handed down from the Supreme Court. With Justice Alito writing the majority opinion and joined by Thomas, Gorsuch, Kavanaugh and Barrett, the court overturned Roe v. Wade as well as the 1992 Planned Parenthood of Southeastern Pennsylvania v. Robert P. Casey decision.--In less than 60 minutes following the court's decision, Missouri, which had a -trigger law- on the books, put its ban on abortion into effect as Attorney General Eric Schmidt, signed such a statement. --Others states have laws on the books that were never repealed when Roe went into effect. So while these laws in those states were put on -temporary- hiatus by Roe, since they were never removed from the books, those are coming back into play due to today's repealing of Roe. --Mat explained that there are those who want to pass federal legislation that would impose abortion on the states and he also believes we'll see crazy things from the Biden administration to try and force states to include abortion whether it's through Medicaid or Medicare. Then there's also the battle at the state level.--This single news story has many aspects to pay attention to. Mat explained these aspects.

The COVID-19 pandemic has led people to delay testing and treatments for a variety of diseases and conditions. This includes HIV testing.During the pandemic, the number HIV diagnosis decline, but that decline is most attributed to declines in testing, according to the Centers for Disease Control and Prevention. Experts attribute this decline to less frequent visits to health centers, reduced outreach services, and shifting of public health staff to COVID-19 response activities. June 27 is National HIV Testing Day, a day to encourage people to get tested for HIV, know their status, and get linked to care and treatment.But who should be tested?"The CDC recommends that everyone over the age of 13 be tested for HIV at least once in their lifetime," says Dr. Stacey Rizza, an infectious diseases specialist at Mayo Clinic. "This is endorsed by the Center for Medicare & Medicaid Services and paid for by all private insurance companies. So no matter what your background is, if you've never been tested for HIV, you should get tested. And that's because many people with HIV have no idea they have it. They can be completely asymptomatic for a very long time and not only have the virus causing ill effects on themselves, but they're at risk of potentially transmitting it to others. We need to do a better job in the U.S., particularly as health care providers, to follow that recommendation, and to make sure that every adult has had an HIV test at least once in a lifetime." If HIV is not treated, it can lead to AIDS. But effective therapies can control HIV, which is why getting tested and seeking treatment is so important."We know now that if somebody is on effective HIV therapy, and the virus in their body is suppressed, it's not gone. But it's suppressed. Their risk of transmitting it to somebody else is close to zero," explains Dr. Rizza. "So if you just pause for a minute and think about that implication. That means if every human on planet Earth who had HIV were diagnosed, linked with health care, and on effective therapy, then HIV would be gone from the human race in one generation."Like many other areas of health care, health disparities play a significant role when it comes to testing, diagnosis and treatment of HIV. Those disparities have been exacerbated by the COVID-19 pandemic. Improving awareness and community outreach can help combat these disparities."It's the same old thing that works for every disease state," says Dr. Rizza. "Its education, engagement and role-modeling within the communities. That education is essential. And it needs to be done in the community. We can't wait for people to come to us, and then we'll teach them, we need to get into those worlds, with people who are leaders in those communities, and have ways to bring diagnosis, treatment and preventive measures to them." Dr. Rizza says disparities in diagnosing HIV face an additional challenge that some other diseases do not: stigma."It is just heartbreaking," says Dr. Rizza. "And the stigma that had been around HIV for a very long time is part of what prevents people from coming forward, from taking the initiatives to prevent the disease, to prevent the infection — and also to be diagnosed — out of fear of the answer. And, so, we also need those community leaders to help break down the stigma issue in addition to educating and bringing diagnosis and treatment closer to home."On the Mayo Clinic Q&A podcast, Dr. Rizza discusses the importance of HIV testing and improvements in therapies to treat HIV.

It's “In the News..” got a few minutes? Get caught up! Top stories this week: The US Senate may have a bipartisan plan to lower the price of insulin for the insured, nasal insulin is tested to reduce the risk of Alzheimer's in people with diabetes, two interesting studies about sleep and diabetes, and more! Check out Stacey's book: The World's Worst Diabetes Mom! Join the Diabetes Connections Facebook Group! Sign up for our newsletter here ----- Use this link to get one free download and one free month of Audible, available to Diabetes Connections listeners! ----- Episode Transcription Below (or coming soon!) Please visit our Sponsors & Partners - they help make the show possible! *Click here to learn more about OMNIPOD* *Click here to learn more about AFREZZA* *Click here to learn more about DEXCOM* Hello and welcome to Diabetes Connections In the News! I'm Stacey Simms and these are the top diabetes stories and headlines of the past seven days. XX In the news is brought to you by T1D Exchange! T1D Exchange is a nonprofit organization dedicated to improving outcomes for the entire T1D population. https://t1dexchange.org/stacey/ XX Two Senators have unveiled legislation aimed at lowering the cost of insulin, but not for the uninsured. This is a bipartisan bill that would lower patietn's cost to 35-dollars a month, for those with commercial insurance and on Medicare. It would eliminate the rebates drug companies pay to negotiators known as pharmacy benefit managers if the drug company kept the overall price of insulin below a certain level. Democrats are also in the midst of talks on a party-line package on President Biden's economic agenda that would likely include reductions in insulin costs as well as broader measures aimed at lowering drug prices, which could complicate any push for a stand-alone insulin measure. This change has enormous support among Americans, but can't seem to get any real traction in Washington despite who's in power. We'll see what happens.. https://thehill.com/policy/healthcare/3531954-bipartisan-pair-of-senators-unveils-bill-to-lower-insulin-costs/ XX Nasal insulin doesn't look like it works too well on diabetes, but a new study shows it may help to slow age related mental decline. This study found that after 12 months of once daily intranasal insulin, people with diabetes in the study performed better on cognitive tests than those diabetics in the placebo group. The non-diabetic group receiving the intranasal insulin also displayed improvements on decision making and verbal memory tests compared to non-diabetics in the placebo group. The biggest improvements in the non-diabetic group were seen in those subjects who started the trial in a prediabetic state. This suggests the treatment may be most effective at slowing cognitive decline in either diabetics or those with prediabetes. https://newatlas.com/health-wellbeing/insulin-nasal-spray-cognitive-decline-dementia-clinical-trial/ XX Go to sleep, and don't breathe too much. Researchers in the U.K. will test hypoxia to treat type 2 diabetes. Hypoxia is a state where the body does not receive sufficient amounts of oxygen. Multiple studies have shown that hypoxia improves blood sugar levels and aids in weight loss. Although scientists do not fully understand how this works, it is suggested that hypoxia burns more calories in the body, resulting in lower appetites in individuals. These researchers want to recruit volunteers so they can figure out why. Each volunteer will be provided with a sleeping tent in which they have to sleep – at home - for 10-day periods on two separate occasions. For one of they nights, they oxygen levels will be set to 15 percent. That sounds ridiculous, but, the air we breathe right now is only about 21% oxygen. 15-percent is pretty typical for find at high altitudes or inside an airplane. https://interestingengineering.com/lose-weight-while-asleep XX Another look at sleeping and type 2.. an exposure to light may increase the risk. Big sleep study at Northwestern University found that exposure to any amount of light during the sleep period was correlated with the higher prevalence of diabetes, obesity and hypertension in both older men and women. A study published earlier this year by the same team found for healthy adults in their 20s. Sleeping for only one night with a dim light, such as a TV set with the sound off, raised the blood sugar and heart rate. An elevated heart rate at night has been shown in prior studies to be a risk factor for future heart disease and early death, while higher blood sugar levels are a sign of insulin resistance, which can ultimately lead to type 2 diabetes. Instead of pulling people into a sleep lab, the new study used a real-world setting. Researchers gave 552 men and women between the ages of 63 and 84 an actigraph, a small device worn like a wristwatch that measures sleep cycles, average movement and light exposure. Fewer than half of the adults in the study got five hours of darkness at night. those who had higher amounts of light at night were also the most likely to have diabetes, obesity or hypertension." Strategies for reducing light levels at night include positioning your bed away from windows or using light-blocking window shades. Don't charge laptops and cellphones in your bedroom where melatonin-altering blue light can disrupt your sleep. If low levels of light persist, try a sleep mask to shelter your eyes. In that case, consider using nightlights positioned very low to the ground, and choose lights with an amber or red color. That spectrum of light has a longer wavelength, and is less intrusive and disruptive to our circadian rhythm, or body clock, than shorter wavelengths such as blue light. https://www.cnn.com/2022/06/22/health/light-exposure-sleep-study-wellness/index.html XX https://medicalxpress.com/news/2022-06-reveals-key-diabetes-drug-nature.htmlXX XX Nice story out of Kansas City where Chiefs offensive tackle Orlando Brown Jr. publicly enrolled himself in a TrialNet study. His brother lives with type 1 and his father died of DKA without knowing he had diabetes. Brown said he hopes participating in the trial will help others while helping himself and his family. https://www.kshb.com/sports/chiefs-orlando-brown-jr-enrolls-in-trialnet-study-for-type-1-diabetes XX Right back to the news in a moment but first As I mentioned, The T1D Exchange Registry is an online research study, designed to harness the power of individuals with type 1 diabetes. It's a research study conducted online over time, designed to foster innovation and improve the lives of people with T1D. Personal information remains confidential and participation is fully voluntary. Once enrolled, participants will complete annual surveys and have the opportunity to sign up for other studies on specific topics related to T1D. By sharing opinions, experiences and data, patients can help advance meaningful T1D treatment, care and policy Sign up at T1DExchange.org slash Stacey (that's S-T-A-C-E-Y). XX Congrats to the great team of Ginger Vieira and Mike Lawson on their newest book. Ain't Gonna Hide My T1D. Sherry the Sheep loves to draw and play basketball, but she's worried about what her friends will think if they see her insulin & CGM. Ginger and Mike are long time advocates who both live with type 1. This is their 3rd children's book together and I think they do a great job of balancing fun and education. https://smile.amazon.com/Aint-Gonna-Hide-My-T1D/dp/B0B455DL45/ref=sr_1_4?qid=1655748198&refinements=p_27:GingerVieira&s=books&sr=1-4&text=GingerVieira XX And finally, The Human Trial premieres this weekend. This is a documentary all about stem cell transplantation as a functional cure for type 1. I first spoke to the people behind this film back in 2016 when they were well underway. The movie follows the first two patients in the Viacyte trials. You can host your own screening.. I'll link up more information – as I do with all of these stories - in the show notes. XX And.. The Human Trial will be subject of next week's long format show. My interview with Lisa Hepner is a follow up to the one six years ago when we first discussed this project. We go into the details of stem cell research, what changed and what she's seen behind the scenes. The current long-format episode out now is all about Skirt My Pump, an ingenious idea from a women who's lived with type 1 for 40 years and got fed up with figuring out where to put her pump. Listen wherever you get your podcasts That's In the News for this week.. if you like it, please share it! Thanks for joining me! See you back here soon.

As part of Pride Month, listen to Health Affairs' Jessica Bylander and Kathleen Haddad discuss the White House's executive order on LGBTQI+ equality and its impact on health care.Related Links: Privately Insured Transgender People Are At Elevated Risk For Chronic Conditions Compared With Cisgender Counterparts (Health Affairs) Podcast: A Health Podyssey with Landon Hughes Lesbian, Gay, And Bisexual Adults Report Continued Problems Affording Care Despite Coverage Gains (Health Affairs) The Battle Over Gender Therapy (The New York Times Magazine) 2022 National Survey on LGBTQ Youth Mental Health (The Trevor Project) Currently, more than 70 percent of our content is freely available — and we'd like to keep it that way. With your support, we can continue to keep our digital publication Forefront and podcasts free for everyone.Subscribe: RSS | Apple Podcasts | Spotify | Castro | Stitcher | Deezer | Overcast

In this podcast, Chris interviews Christopher Morrissette.  Christopher is the COO of Serious Illness Care and Chief Strategy Officer for Teleios Collaborative Network.  This is a great listen to understand the challenges facing our country due to the rising costs of healthcare and why palliative care and serious illness care is part of the solution.  Christopher lays out how innovation, technology, and serious illness care will play a role in a brighter future for healthcare. Our GuestChristopher MorrissetteCOO of Serious Illness Care and Chief Strategy OfficerTeleios Collaborative NetworkBioChristopher Morrissette, MBA over 20 years of extensive operational experience within Serious Illness Care including Palliative Care, hospice, homecare and long-term care. Christopher joined TCN when founded in 2017 and has supported the development of serious illness care models, payer strategy, Business Intellegence and the formation of the Clinically Integrated Network. Tools from this podcast:Some applicable stats:The year 2030 marks a demographic turning point for the United States. Beginning that year, all baby boomers will be older than 65 years of age.This will expand the size of the older population so that one in every five Americans is projected to be of retirement age.The Gross Domestic spending on healthcare was 19.7% according to 2020 data. Previously, GDP was 17% for the prior 10 years.US national healthcare expenditure reached $4.1 trillion in 2020, or $12,530 per person, and is estimated to reach $6.2 trillion by 2028, per the Centers for Medicare and Medicaid Services.This is a growth of over 50%, apply same calculation to GDP and we could be looking at minimum ¼ of the US Economy spent on Healthcare for a mediocre product.Our HostChris ComeauxCEO / President of Teleios Collaborative Network

It's almost time for NAHU's Annual Convention! But, before we see your bright smiling faces in Austin, there is some regulatory news to discuss! This week, NAHU submitted comments to CMS in response to a proposed rule released in April that makes policy changes to the Medicare enrollment process, among other important changes. On this week's episode of the Healthcare Happy Hour, NAHU's John Greene discusses our comment letter to the administration. Additionally, we discuss how you can complete your Medicare Advantage training with NAHU.

CF 234: Chiropractic For Medicare Patients & Avoiding Vertebral Artery Stress During Adjustments Today we're going to talk about Chiropractic saving Medicare patients money and adverse events and a better position for preventing strokes when adjusting the neck.  But first, here's that sweet sweet bumper music   Purchase Dr. Williams's book, a perfect educational tool... The post Chiropractic For Medicare Patients & Avoiding Vertebral Artery Stress During Adjustments appeared first on Chiropractic Forward.

Welcome to the Informative Conversations Podcast with Host Jacquelyn and Special Guest Cindy Nelson, JD. Topic: The Importance of Preparing for Family Care - Part II In this episode, I continue my discussion with Attorney Cindy Nelson about the Importance of Planning for Family Care. Cindy explains the five things we all need for daily care; benefits for Veterans; Medicare and Medicaid benefits; what happens in Blended families; and how to protect your underage children. Cindy shares the details about things we all need to live comfortably in every stage of life.   Cindy Nelson is an Attorney and the Founder of Nelson Elder Care Law. She specializes in protecting her client's life savings in addition to representing seniors' rights and interests. Ms. Nelson is a frequently requested speaker for educational events across the metro Atlanta area. Nelson Elder Care Law is the recipient of national, state, and local awards for their knowledge in Elder Law and the service they provide for their clients. Cindy is a Member of the Georgia Bar Association and the National Association of Elder Law Attorneys. Happy Listening! Did this episode "speak to you?"  Leave me a comment and subscribe to the show at up2meradio.com/informative-conversations-with-jacquelyn/ Like and follow us on Facebook at Up2Me Radio, Instagram at Up2Me.radio and on Twitter at Up2Me Radio

So, this is a 400-level episode in specialty pharmacy options for plan sponsors, meaning here are your prerequisites: You gotta know what buy and bill is, and you gotta know what pharmacy bagging is, meaning white bagging, for example. If you do not, I would listen to Encore! EP282 with Aaron Mitchell, MD, MPH, where we go deep on buy and bill. And then listen to EP369 for the skinny on pharmacy bagging. If you already know what buy and bill is and you already know what white bagging is, then not only do you know more than 98% of the people in the healthcare industry, but also, you're going to get as much out of this conversation with Erik Davis and Autumn Yongchu as I did.   Last week's show was also with Erik Davis and Autumn Yongchu. Last week, we talked about how some hospitals and cancer centers are managing to ring up up to six times the cost of an expensive-already injected or infused drug through buy and bill. This is why pharmacy bagging became a thing, if we want to talk about this in historical perspective. It's a direct market response to buy and bill. Hospital systems start making egregious amounts of money marking up drugs that already cost hundreds of thousands of dollars, and their markups are hundreds of thousands of dollars on top of that. Hospital starts making a fortune off of drug markups. Plan sponsors need an alternative, and … enter pharmacy bagging (ie, carving out specialty pharmacy drugs to a PBM [pharmacy benefit manager]). In this show, we compare the potential benefits and problematic loopholes and/or patient concerns for plan sponsors who are trying to figure out whether to carve out specialty pharmacy benefits to a PBM or grin and bear it with the buy and bill. Or, as another option, whether to steer patients to specific infusion centers or specific provider organizations that might have more favorable contract terms for the plan sponsor. Or, hooking up with a home infusion company, again, who is willing to negotiate terms that might be far better for said plan sponsor than just letting some hospital have their way with employees and the health plan. As another alternative, of course, plan sponsors could consider medical travel, which some certainly are. My biggest takeaway from this whole conversation and from the episodes that we have had in this, dare I call it, series about pharmacy benefits, starting with the show with Scott Haas (EP365) where we talked about PBM contracts, moving to the show with Dr. Aaron Mitchell (Encore! EP282) where we talked about buy and bill, then going to the show with Keith Hartman (EP369) where we talked about pharmacy bagging, then last week's show how hospitals manage to buy and bill at 6x the price of these expensive pharmaceuticals … my takeaway from this whole specialty drug extravaganza is that specialty drug procurement is very different than retail drug procurement. Retail drugs, you worry about them en masse at scale almost at the population level. Specialty drugs? You can have one patient on a specialty drug, and that one patient costs as much as the entire rest of the member population combined. So, managing specialty drugs and their administration becomes almost a case-by-case operation. What drug is it? Where is the patient? What options are available? It's possible to save hundreds of thousands of dollars on that one patient, for that one patient's care, and get better patient outcomes by getting the right patient on the right drug that is administered in the right setting.   You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis, AAI, CIC, CRM, is senior vice president and principal consultant, managed care and analytics, at USI Insurance Services. He has over 30 years of experience in the insurance and risk management industry. Erik works to create an environment that supports the healthcare risk management goals of an organization while maintaining focus on compliance and financial accountability. He is instrumental in vendor negotiations, data benchmarking, population health strategies, claims analysis, recommendations in plan design, and communication strategies. In this capacity, Erik has been involved with development of rates, payment structures, and recommendations of changes in processes, policies, and procedures. He has a broad understanding of contract analysis, evaluating risk, auditing for correct payment, and structuring of excess loss and pharmacy programs. Erik's experience extends from overall employee benefits consulting to workers' compensation, as well as managed care organizations in Medicaid, Medicare, and commercial contractual risk arrangements. Erik earned his bachelor's degree in economics from Oregon State University. He holds Accredited Advisor in Insurance (AAI), Certified Insurance Counselor (CIC), and Certified Risk Manager (CRM) designations. Autumn Yongchu is a healthcare operational risk consultant at USI Insurance Services. Autumn works with multiple database platforms to examine data for trends and abnormalities. Using investigative querying, medical coding analysis, and report development, she provides resources that help identify cost control opportunities and assists organizations in strategic business decisions regarding the management of healthcare risks. Autumn analyzes and interprets healthcare utilization data, allowing the development of initiatives regarding claim and risk management. This includes identifying fiscal and clinical strategies and providing necessary information to develop, design, and implement management initiatives. Autumn also analyzes trends, assists with insurance underwriting, and adjudicates stop-loss claims. Autumn has an in-depth knowledge of Medicaid and Medicare billing guidelines and payment methodologies. Prior to joining USI, Autumn was a claims auditor and trainer for a managed care organization which serviced over 100,000 commercial, Medicaid, and Medicare lives. Her responsibilities included contract analysis, claims adjudication, ensuring accurate payment, and identifying and recouping errors. 04:45 Can you actually save money by carving out specialty infused drugs and making them a pharmacy benefit? 06:28 How can plan sponsors use white bagging as leverage to reduce costs from markups? 06:47 Does white bagging save money compared to buy and bill? 07:42 “You also need to understand that with some of these drugs, you're dealing with very vulnerable people.”—Erik 08:41 EP369 with Keith Hartman, RPh. 11:10 “When your insurance carrier is married to your PBM, it doesn't matter where the money goes.”—Autumn 11:33 EP365 with Scott Haas. 12:00 “You need to have a collective understanding of every variable … when you're making those … decisions.”—Erik 14:53 How can comparison shopping save plan sponsors money when it comes to specialty infusion costs? 16:51 How can comparison shopping be a vicious circle in the wrong setting for plan sponsors? 18:43 “That's part of the problem: It's not just the plan sponsor not being educated enough; it's also the consultant … that they believe is supposed to be that isn't.”—Erik 19:03 How has transparency been used by healthcare systems to keep buyers' eyes off the ball? 26:55 “It is very case by case, but it comes down to your risk appetite.”—Autumn 28:19 “It's something that you have to, as a plan sponsor, really continue to monitor throughout the plan year.”—Autumn 28:38 “The more you know, the better equipped you're gonna be.”—Autumn 29:27 What can employers who are feeling aggressive do? 31:19 “The dollars circle, whether people realize it or not.”—Autumn You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma Can you actually save money by carving out specialty infused drugs and making them a pharmacy benefit? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How can plan sponsors use white bagging as leverage to reduce costs from markups? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma Does white bagging save money compared to buy and bill? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “You also need to understand that with some of these drugs, you're dealing with very vulnerable people.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “When your insurance carrier is married to your PBM, it doesn't matter where the money goes.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “You need to have a collective understanding of every variable … when you're making those … decisions.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How can comparison shopping save plan sponsors money when it comes to specialty infusion costs? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How can comparison shopping be a vicious circle in the wrong setting for plan sponsors? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “That's part of the problem: It's not just the plan sponsor not being educated enough; it's also the consultant … that they believe is supposed to be that isn't.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma How has transparency been used by healthcare systems to keep buyers' eyes off the ball? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “It is very case by case, but it comes down to your risk appetite.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “It's something that you have to, as a plan sponsor, really continue to monitor throughout the plan year.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “The more you know, the better equipped you're gonna be.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma What can employers who are feeling aggressive do? Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma “The dollars circle, whether people realize it or not.” Erik Davis and Autumn Yongchu discuss #buyandbill and #pharmabagging on our #healthcarepodcast. #healthcare #podcast #pharmacy #pharma   Recent past interviews: Click a guest's name for their latest RHV episode! Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger  

Today I'm sharing a fun announcement with everyone. I'm also providing retirement savers with important information on the 2022 Medicare IRMAA brackets. This includes covering three things: What IRMAA is How IRMAA is calculated The 10 best ways to avoid IRMAA If you want to better understand how you can navigate Medicare IRMAA this year (and beyond!), you'll enjoy this episode. Important links for this episode:

Spencer Hutchins got his startup experience right out of Colby College, with a senior role in John Kerry's presidential campaign. From there he took on a series of government and policy roles before co-founding Reflexion, a rehab software company.And then in 2016 he founded Concert Health, which helps independent physician practices deliver integrated behavioral health services. In essence it's a group practice that leverages Collaborative Care Management reimbursement from Medicare, commercial insurers and now Medicaid to do the right thing for patients.

The Federal Reserve is raising rates at a fast pace to fight inflation. This has created a lot of volatility in the stock/bond markets. These Fed rate changes ultimately lead to interest rate increases for mortgages and other debts. Yet, these increases might actually be a good thing, particularly for retirees.

When confronted with a complaint, allegation or event that implicates a potential Medicare overpayment, hospices have an affirmative duty under the federal 60-day repayment rule to conduct an investigation and refund any overpayment. In this episode, Husch Blackwell's Meg Pekarske and Andrew Brenton share tips and tools for conducting internal investigations and determining when an issue implicates payment.

Tune into the second episode in the Avalere Health Essential Voice podcast series focused on the how CMS and Medicare coverage decisions define patient access. In this segment, our experts continue the conversation around national coverage determinations (NCDs)that have coverage with evidence development (CED) requirements, how FDA and CMS's evidence questions can be complimentary, and the ways in which manufacturer evidence generation plans can address those goals, using the NCD on monoclonal antibodies for Alzheimer's disease as an example.

If you are still in the market to buy a house, you probably know interest rates are increasing sharply. Host Teri Barr is talking with Kate Wood, a Mortgage Expert with NerdWallet, to learn how we got here and why it's important. Kate also discusses what could happen next, and if you still want to buy a home, she has a few ideas to consider when you lock in your rate Previous Pennywise episodes featuring Kate: Proposed Changes to Medicare and How They Could Impact You More from Kate at NerdWallet: Fed Hoists Key Interest Rate as Mortgage Rates Reach New Heights What Are Real Estate Agent Networks? What Does a Real Estate Agent Do? Support the show: https://omny.fm/shows/pennywise See omnystudio.com/listener for privacy information.

In January of this year, entrepreneur and Dallas Mavericks owner Mark Cuban launched a direct-to-consumer pharmacy called the Cost Plus Drug Company, promising savings by eliminating middlemen and charging cost plus 15% and a pharmacy fee. What if Medicare could do the same? On this episode of Managed Care Cast, we speak with a researcher who coauthored a study out this week that looked at the savings to Medicare Part D if the same model had been employed for some of the most used generic drugs. Hussain S. Lalani, MD, MPH, an internist and one of the coauthors, discussed the findings of the paper, published Monday in the Annals of Internal Medicine. The analysis compared the price paid by Medicare Part D plans in 2020 with the price of 89 generic drugs sold by the pharmacy in 2022. The researchers, from Brigham and Women's Hospital and Harvard Medical School, used the price paid by Medicare Part D plans in 2020 and looked at the price of 89 generic drugs sold by the pharmacy in 2022. After adjusting for changes in drug costs between 2020 and 2022, the researchers found that Medicare paid more on 77 of the 89 generic drugs: $8.1 billion compared with $4.5 billion. Medicare would have saved as much as $3.6 billion over 1 year.

On this week's episode of Lever Time: David speaks with Alex Lawson, the executive director of Social Security Works, to discuss Lindsey Graham's recent comments on entitlement reform and whether the Biden administration will capitulate to Republicans. He's then joined by Andrew Perez, whose recent Lever story explored a free medical clinic filling critical health care gaps in Sen. Manchin's home state of West Virginia, after the corporate Democrat blocked Medicare expansion. Finally, Julia Rock interviews climate organizer Pete Sikora, a campaign director for New York Communities for Change, about New York Dems' recent efforts to kill a renewable energy bill.If you'd like to support the independent journalism we're doing, head over to LeverNews.com to become a supporting subscriber.If you'd like to leave a tip for The Lever click the following link. We really appreciate your support :) levernews.com/tipjarHead over to SheetsGiggles.com/LEVER to get 15% off your order!

A new study finds Medicare could save $3.6B if it bought generic drugs through Mark Cuban's new pharmacy. Walgreens launches its new clinical trial business. And home health providers are unhappy with Medicare's planned rate cut. See acast.com/privacy for privacy and opt-out information.

  AEP prep season is here and we've got details on AHIP requirements, how certification works for insurance agents, info on AHIP discounts and so much more. Get ready for AEP 2023 is the Agent Survival Guide Podcast! Read the text version. Register for your FREE RitterIM.com account   Frequently Asked Questions about AHIP: [07:25] Do I need to pass AHIP if I already passed last year? [08:09] Do I need to complete the AHIP training review questions? [08:34] How many attempts at the AHIP test do I get? [08:59] How long must I take between failed attempts? [09:30] Do I have to take AHIP directly through their website? [10:00] Do I have to take the training on a computer? [10:14] How much does AHIP cost? [10:25] Can I get an AHIP certification discount? [10:47] Is it possible to get a $125 AHIP reimbursement? [11:02] Is there a deadline to pass AHIP to sell in 2022? [11:23] Is AHIP an open-book test? [11:32] Is AHIP a timed test? [11:54] What score do I need to pass? [12:03] How much should I prepare?   Mentioned in this episode:   Contact the Team at Ritter Insurance Marketing AHIP Medicare + Fraud, Waste, and Abuse (MFWA) Training Site Advocating for Health Insurance Providers and the Patients and Communities They Serve America's Health Insurance Plans (AHIP) Description Find Your Ritter Sales Specialist Register for your FREE RitterIM.com account Ritter's Carrier Certification Center Ritter Carrier Product Info The Survivor's AEP Checklist   More episodes you'll like:   2023 Maximum Broker Commissions for Medicare Advantage and Medicare Part D AHIP Test Tips & Tricks for Medicare Certification How to Check for Your First Looks How to Recruit Insurance Agents to Your Downline Important 2023 AHIP Certification Training Updates You Should Know   Articles to Share with Your Clients:   Dishes to Impress Your Friends: Spring Rolls Ways Seniors Can Save on Groceries What is Medicare's Secondary Payer Program?   Ritter Insurance Marketing eBooks & Guides:   Agent Survival Kits: Beginners or Experts The Complete Guide on How to Sell Medicare Advantage Plans The Complete Guide on How to Sell Prescription Drug Plans The Complete Guide to Client Loyalty and Retention The Definitive Guide to Getting Leads and Prospecting for Medicare Sales   The latest from Ritter's Blog:   FAQs About Selling On-Exchange & Off-Exchange Under-65 Plans How to Check for Your First Looks Lower 2023 Medicare Part B Premium Expected After Reassessment by CMS   Connect on social:   Facebook LinkedIn Twitter YouTube Instagram TikTok Sarah's LinkedIn Sarah's Instagram   Subscribe & Follow:   Apple Podcasts Google Podcasts Overcast Podbean Spotify Stitcher  

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When your doctor prescribes a new medicine, there's a pretty good chance that some snafu will crop up before you get it filled. Either your pharmacy doesn't carry it, or your insurance provider won't cover it, or they'll say you need "prior authorization," or your out-of-pocket cost will be sky-high. The basic problem is that the electronic health record systems and e-prescribing systems at your doctor's office don't include price and benefit information for prescription drugs. All of that information lives on separate systems at your insurance company and your health plan's pharmacy benefit manager, or PBM. And that's the gap that a company called RxRevu is trying to fix. Harry's guest on today's show RxRevu CEO Kyle Kiser, who explains the work the company has done to bring EHR makers, insurers, and PBMs together to make drug cost and coverage information available at the point of care, so doctors and patients can shop together for the best drug at the best price.Please rate and review The Harry Glorikian Show on Apple Podcasts! Here's how to do that from an iPhone, iPad, or iPod touch:1. Open the Podcasts app on your iPhone, iPad, or Mac. 2. Navigate to The Harry Glorikian Show podcast. You can find it by searching for it or selecting it from your library. Just note that you'll have to go to the series page which shows all the episodes, not just the page for a single episode.3. Scroll down to find the subhead titled "Ratings & Reviews."4. Under one of the highlighted reviews, select "Write a Review."5. Next, select a star rating at the top — you have the option of choosing between one and five stars. 6. Using the text box at the top, write a title for your review. Then, in the lower text box, write your review. Your review can be up to 300 words long.7. Once you've finished, select "Send" or "Save" in the top-right corner. 8. If you've never left a podcast review before, enter a nickname. Your nickname will be displayed next to any reviews you leave from here on out. 9. After selecting a nickname, tap OK. Your review may not be immediately visible.That's it! Thanks so much.TranscriptHarry Glorikian: Hello. I'm Harry Glorikian, and this is The Harry Glorikian Show, where we explore how technology is changing everything we know about healthcare.If you live in the United States and you've ever had your doctor prescribe a new medication, you've probably had the following experience.You drive from the doctor's office to the pharmacy.And when you get there, you find out that the pharmacy doesn't carry that particular drug. Or that they do carry it, but your insurance provider doesn't cover it. Or your insurance does cover it, but they require prior authorization. Which means you have to get back in touch with your doctor and ask them to tell the insurance company that you really do need the medicine.Or you already have prior authorization, but you haven't met your annual deductible yet, so your out-of-pocket cost is much more than you expected.If any one of these problems crops up, the chances that you'll actually get your prescription filled on the day you need it go way down.And it's not uncommon for several of these snafus to happen all at once.Fundamentallythat's because the electronic health record systems and the electronic prescribing systems at your doctor's office don't include price and benefit information for prescription drugs.All of that information lives on separate systems at your insurance company and your health plan's pharmacy benefit manager, or PBM.And that's the gap that a company called RxRevu is trying to fix.My guest on today's show is the CEO of RxRevu, Kyle Kiser.We talked about the software they've built to make drug cost and coverage information available within the major EHR systemsWhen doctors can see in real time which drugs are covered, at what price, for a specific patient, it    obviously solves a huge pain point for patients, because it means they're more likely to get the drugs they need at an affordable price.But it also solves a big problem for doctors. Because, fairly or not, they're the ones who usually shoulder the blame when it turns out the medication they just prescribed is too expensive or isn't available.The kind of information RxRevu provides is going to be more and more important as the U.S. enters into an era of far greater price transparency, as mandated by the federal No Surprises Act, which went into effect on January 1 of this year.RxRevu is based in Denver, Colorado, and I reached Kyle Kiser at his home in Seattle, Washington. Here's our full conversation.Harry Glorikian: Kyle, welcome to the show.Kyle Kiser: Thanks, Harry. Happy to be here.Harry Glorikian: So, you know, we were just talking. You're in Seattle and I'm in Boston. I don't think we could be much farther apart when it comes to this particular country. So but let's start with a little bit of background, right. So. You're the CEO of RxRevu. And can you tell us a little bit about sort of the origin story about how you got started here? I mean, I understand your co-founder, Dr. Kevin O'Brien, had an interesting experience trying to get prescriptions filled for his mother, Lucy, but. What's the rest of that story? What did that story reveal to you about what's broken or missing in the way that doctors prescribes medicines or, you know, where the way that maybe payers approve prescription?Kyle Kiser: Yeah, absolutely. So a little background on Kevin's story. Kevin was initially inspired to do this because he wanted to solve a problem for his mom. She had an outsized out-of-pocket spend for meds. Like any good son, he wanted to help solve a problem for his mom. He used his expertise to find sort of ways to save on those medications, and that inspired him to start doing that in his clinic for his patients more comprehensively. So he was, you know, way ahead of his time and putting in all of this extra effort to really help find prescription options for patients that they could afford more easily. And that was the initial inspiration for what we've done today, which is connecting the point of care and clinical decision making with costs and coverage information that's real time and patient specific and location specific and moment in time specific, because all those things matter as inputs into a price.Kyle Kiser: So, you know, really the challenge we've been focused on is, is largely that, you know, the clinical decision making process has been pretty, pretty much disconnected, right, from marketplace information. So, you know, anything that impacts the purchasing of that care. And that was okay in a world where deductibles were low, formularies were relatively inexpensive and simple. But that world has changed dramatically over the last 10 to 20 years, right, as consumer driven healthcare has become the way of the world. And first dollar risk is now at the feet of the patient. It's that patients are now demanding that providers can consider not just what's best from a clinical perspective, but also set expectations around costs, set expectations around any restrictions that exist, and be an advocate for access to care. And the problem we're solving. We're building an access network. And within that access network, we help drive affordability and speed to care for patients. And we're doing that with a number of stakeholders. But at a high level, that's what we're trying to accomplish.Harry Glorikian: Well, you know, it's interesting, right? You know, entrepreneurship 101, solve a real need, right? So that there's a market there because everybody wants it. But so, I mean, look, I think everyone in the United States has probably had experiences similar to Dr. O'Brien's mom. I mean, you get to the pharmacy, you find out that the medication your doctor prescribed isn't covered by your plan, or you find out that the co-pay is outrageously high. But behind their personal experiences, I bet most people don't have a concept of how big and widespread this problem is. You know, you have any maybe some statistics that might illustrate the scale of the problem or how much money is wasted in the medical system because of these disconnects. I mean, I'm wondering how many prescriptions get abandoned or how many patients don't get the meds they need.Kyle Kiser: Yeah, I mean, at a. A macro level, you know, the prescription drug market makes just over makes up, you know, just over a half a trillion. Right. And, you know, estimates are that a third, even as much as half of that is waste and waste in the form of, you know, medications that aren't taken as prescribed or aren't delivering the right outcomes. I don't it's hard to find actually a a stakeholder in the supply chain that's delivered more value than meds themselves. I mean, if you think about, you know, the innovation in that world over the last 30 years, it's second to none. But the, you know, the supply chain within which they exist is complicated and it's hard to navigate. And the consequences of that is waste. And, you know, a ton of administrivia and friction. And frankly, patients bear the brunt of that. Ultimately, it's health plans and PBMs and risk bearing entities making rules on one end. It's providers and care teams making clinical decisions on the other end. And both of those processes are largely disconnected. And the only way that that gets harmonized in any way is a patient advocating for themselves. And we just fundamentally don't believe it should happen that way. What we're building is the connectivity between those stakeholders so that whether it's a provider at the point of care making the decision, whether it's a care team member trying to help you overcome a prior, or whether it's a patient trying to advocate for themselves using their own technology, we want to put real time, patient-specific, moment in time specific information in their hands to drive affordability and speed to care for that patient, no matter where they are in the care continuum.Harry Glorikian: Yeah. I mean, so this lack of prescription cost data, I mean at the point of care feels like a real canonical example of deep systemic problems with the with origins that are buried like deep in at least three of these complex organizations. Providers, payers and EHR makers. I mean, once you guys decided what the problem you wanted to fix was, how the hell did you figure out where to like -- okay, let's start here and let's move forward, right? Because.Kyle Kiser: Yeah.Harry Glorikian: Not trivial.Kyle Kiser: No, it's exactly the right observation because ultimately what we're building is a multi-sided network. And what's difficult about building a multi-sided network is, you know, users on one end, in this case, providers, aren't going to engage if it doesn't have the appropriate information in it. And the data sources, the ability to capture that appropriate information, they don't want to provide that data to you unless you have the appropriate users. So you get stuck in this chicken or the egg problem. And that's job one in growing this business, is to overcome that chicken or the egg problem. And the way we went about that was we worked really closely with health systems, with provider organizations, primarily because that's where the trust exists, is that ultimately patients seek out their provider and their care team to answer these questions. And so we worked closely with them as strategic partners and brought some of them in as investors in the company and aggregated a group of meaningful collaborators on the health system side, which then helped us bring PBMs and payers to the table to say, how do we solve these problems together? And that's that's sort of how we got out of the gate.Harry Glorikian: So I mean, tell me if we could dig a little into I think the product is called SwiftRx, if I remember correctly, but at a high level. You know, if you could describe for listeners, what is it? How does it work? And. Where does it fit in relation to the overall system?Kyle Kiser: Sure. Yes. So SwiftRx Direct is the product you're describing. What it provides is, is that real time, patient specific, location specific, moment in time specific information in the provider's native ordering workflow. So we are a data network that's powering a native feature inside the EMR that provides that insight while providers are selecting medications. So a typical flow would look like, a provider selects a medication. They then place that into a pending status in the software that they use. When that happens, we're able to gain visibility to that choice. We send that transaction out to our network of data sources, payers, PBMs, etc.. And what we get back is the price that is patient specific. We have formulary insights, so prior auth, quantity, limit, step therapy, those sorts of things. Those are also patient specific. And then most importantly, we get back alternatives. And those alternatives come in two forms. They're either a lower cost medication or a lower cost pharmacy where the patient can fulfill that medication. And that's sort of the core information that we then render back into the e-prescribing workflow. And we only interrupt those providers' workflows, or we and our partners only interrupt those providers workflows, when there's relevant information to consider. Because as I'm sure, you know, being deep in this world, provider engagement stuff -- you really have to be thoughtful about when, when is the appropriate time to intervene and when, when do we want to sort of get out of the way and make sure that when we are intervening, it's meaningful and understood to be meaningful?Harry Glorikian: Yeah. So I'm going to I mean, I heard a lot of what you said. I'm I want to maybe summarize all the. A few of these areas that people run into problems. But to try to understand sort of what are the big problems you had to solve to get it to really work? Because I'm just trying to get my head around the magnitude of the data headache here. Right. So if if you'll allow me, I'll just try to break it down into parts and then you can tell me how you're bridging all of these. So for one thing, there's the patient specific data about what kind of insurance each patient has and what level of benefits they have. And none of that is stored in the EHR at the clinic. As far as I know, typically the EHR would only list the patient's group number, subscription number or maybe the RxBin number. And then separate from all that, every insurance has a formula of drugs that will cover and sometimes a, you know, a schedule of different copay amounts for those drugs. And those formularies change every year and even more often. Right. And then there's a patient's actual prescription data which may live in their EMR or may live in a different system at the pharmacy. And then on top of that, there's this obscure black box system of prior authorization criteria that insurers may use to deny a prescription if they don't feel like paying for it. So the fact that the system is so fragmented is a familiar story to anybody who listens to this show. But tell me, you know, how on earth you were able to sort of get all this data under one roof, so to speak? You know, is there a specific architecture of the Swift system that makes you good at collecting all of this changing data and presenting it to the providers in real time?Kyle Kiser: Yeah. The only other element I'd add to your complexity salad is also benefit design, right. Is that yeah, the, the out-of-pocket cost can be and is dramatically different based on where you are in your coverage. If you're a commercial member with a high deductible, you're bearing the, you know, the in-network negotiated rate inside that deductible. And that changes pretty dramatically once you reach a deductible. Or if you're a Medicare member, there's the donut hole. And all of those things are also inputs and complexity to add to this. So to answer your question, it's really working closely with the stakeholders that control those, that are the source of that data. Right. You really can't get to an accurate price without working with those with those data sources specifically. So we work closely with the PBM, with the payer, and we do more or less a mock adjudication. So the same type of adjudication activity that happens on their end when a patient arrives at the point of sale is happening when a provider is making a prescribing decision in this case.Harry Glorikian: I mean, I can tell you, like the last time I had to sit and choose an insurer, and you would think that I'd be better at this than most, I remember having to take two Tylenol, because when I got done, because I thought my head was going to explode. And I could honestly not say to you I made the best choice. It was at the end, it was almost like a Hail Mary, I guess with all the complexity. And the other thing that I keep thinking about is when I used to watch, I think if you have kids, you've watched The Incredibles and there's a point in the show where the manager says they're penetrating inside of our systems to understand how to get how to get the system to pay them or whatever. It feels like it's that level of complexity. And you really need a sophisticated system to sort of bring all that information together to make sense of it all.Kyle Kiser: Yeah, that's true. And it is it is dynamic, it is highly variable and it's very different from administrator to administrator. Right. And a specific example of that, right, is that responses we get back are not across the board consistent, that here's an error and here's what that error means. And that error message is consistent from health plan to health plan. That's just not the way the world works, right. The error messages are specific to those claim systems because ultimately on the other side of the fence, these are mainframe systems in some cases that were designed decades ago that they've then created a layer to expose to the outside world, in this case us. And, you know, it's not simple work for us or for them. So I think the thing also to point out here is that there's a lot of effort from the payer- rrPBM community to make this accessible and to sort of change the way they're doing business and to change the way their technology works to enable some of these things, which is which is progress and should be commended for sure.[musical interlude]Harry Glorikian: Let's pause the conversation for a minute to talk about one small but important thing you can do, to help keep the podcast going. And that's leave a rating and a review for the show on Apple Podcasts.All you have to do is open the Apple Podcasts app on your smartphone, search for The Harry Glorikian Show, and scroll down to the Ratings & Reviews section. Tap the stars to rate the show, and then tap the link that says Write a Review to leave your comments. It'll only take a minute, but you'll be doing a lot to help other listeners discover the show.And one more thing. If you like the interviews we do here on the show I know you'll like my new book, The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer.It's a friendly and accessible tour of all the ways today's information technologies are helping us diagnose diseases faster, treat them more precisely, and create personalized diet and exercise programs to prevent them in the first place.The book is now available in print and ebook formats. Just go to Amazon or Barnes & Noble and search for The Future You by Harry Glorikian.And now, back to the show.[musical interlude]Harry Glorikian: Interesting. So if I'm not mistaken, both Epic and Cerner have made it possible for providers to embed SwiftRx into their EHR. So if I understand it correctly, it even comes as a standard part of Cerner now. So those are two of the biggest EHR providers in the US.Kyle Kiser: And Athena.Harry Glorikian: And Athena, so question: how did you make that happen?Kyle Kiser: Well, you know, we've got a great team and the team executed ultimately. We worked really hard on those relationships. And I think it's both working with the right customers in small ways in the early days that leads to working with these types of partners and bigger ways. And frankly, some of the open programs at some of these places led to this. So early days, we were working in kind of the more open developer type programs with these EMR partners. We were working closely with some of their customers. Banner was one of our first customers. UC Health was one of our first customers, both a Cerner and an Epic user respectively, and, you know, is working in small ways to solve these problems together with those health systems that led us both to interacting with PBMs and ultimately building these enterprise level relationships with the EMR. It's, you know, it's, it's earning the trust, it's delivering for these customers and then earning the right to do this at scale. And we're to a point now where we'll do almost 100 million of these transactions this year. And it's you know, it's grown fast.Harry Glorikian: Yeah, that's a lot of that's a lot of data flowing back and forth. But so let's ask the money question, like, what's the business model? Who ends up paying you? Is it the provider buying SwiftRx as an add on to the existing EHR or how does that work?Kyle Kiser: It's the risk bearing entity ultimately. So think about that as payer and PBM. In most cases, there are cases where we work with health systems and there are some things we do that that are either channel related or related to specific needs that they have when they're that risk bearing entity. But at a high level, we follow the risk and we want to work with the customer that is bearing that risk because ultimately they're the ones that stand to benefit from an optimized prescription choice.Harry Glorikian: Okay. So that everybody gets a clear idea of like, can you give me a before and after picture at a clinic that brings SwiftRx into their EHR?Kyle Kiser: Sure. Yeah. So. You know, this is probably an experience many of many of the listeners have had. Right. Is that. Before such acts you interact with your physician, they diagnose you with whatever condition they've perceived. They select a medication. They route it to the pharmacy. You go to the pharmacy and cross your fingers that all of the requirements have been met. And that is at a price that you can afford if there is a prior or if that's too expensive. When you arrive at that site of fulfillment, you discover that, right, if there's a prior that's not been completed, then you've got to go through that prior authorization process and you're not picking up that prescription today. If it's a price you can't afford, you got to figure out how to pay for it. And there's a variety of ways that that happens. But ultimately, it's up to the patient to figure those things out. In a world where SwiftRx is installed, the difference is, as that prescription decision is happening, we notify the prescriber of the patient's out-of-pocket cost. In some cases, even the plan cost associated with that choice. Any restrictions that exist like prior or quantity limit or step therapy. And we also notify them of any lower cost alternatives. So in many cases, simple changes make big differences in in the out-of-pocket cost. And it might even be something as simple as, time release metformin can be hundreds if not $1,000, and regular old metformin is four bucks and has been four bucks for decades.Kyle Kiser: So it's some of those almost unintentional, I hesitate to call them errors on the provider side. It's just they're making choices based on their own sort of clinical expertise. But they don't they don't know these things, right? They don't know how a time release metformin might be reimbursed for one of the ten or 12 payers that they may see in a given clinic day. So it's just providing that insight upfront so that they can make those decisions and understand the trade offs. Is time release really important or is this patient going to be fine? And is that out-of-pocket costs for a med going to prevent them from being able to actually take that medication? And as a result, they're not going to receive any of the clinical benefit. So ultimately, the $4 option is probably better. So it's really connecting that clinical decision making process with all of the complexity that exists on the payer and PBM end so that we can get the decision right the first time. And when the patient shows up at the pharmacy, they know how much is going to cost, they feel comfortable that they can pay for it and they're either aware of the prior auth and have already completed the requirements or have some, some level of expectations set to how to complete those requirements.Harry Glorikian: So for all the reasons we've been discussing, doctors traditionally have been able to stay somewhat separated or maybe called it shielded from discussions about drug prices. I mean, they just prescribe a drug, leave it to their office staff or the patient or their pharmacy to figure out whether it's covered. But now, for organizations that are using your system that are built into their EHR, a clinical encounter, it can involve essentially going shopping in real time for the best drug at the best price. I mean, in your experience, how do doctors like being pulled into these decisions? I mean, I can see how it be great for patients, but I wonder if doctors are equally excited.Kyle Kiser: You know, one of the things that's been the most surprising to us around this subject, specifically patient out-of-pocket cost, is one of the most requested pieces of information in a primary care clinic, because it's so complex and it creates so many callbacks and it creates so much patient dissatisfaction. Because ultimately the patient's going to, at some level, hold that prescriber accountable for that decision. And if it's really expensive med there's an assumption that the provider knew that already or should have known that, whether that's true or not. And so what that's resulted in is primary care providers want this information, they want it. They want to have this at their fingertips when they're making decisions. It's the world certainly changed in that way. So I think, you know, it's becoming a part of the standard of care being able to consider cost. Because to the point earlier, the only medication that works is the one the patient can afford. And so you really have to consider those things because of the way our sort of health care payment infrastructure exists. Right. There's just, patients are bearing a dramatic portion of that cost these days and got to consider that as a part of the way you deliver care.Harry Glorikian: I mean, I almost feel like your company is is pushing. These providers and payers and to fix the prescription benefit system or making them more efficient or compatible.Kyle Kiser: Yeah. I think there is a, I maybe describe it as rationalizing. R I don't think that a clinical team and a PBM and PNT committee at a health system have dramatically different opinions on what medications should be prescribed, for what conditions. The friction exists in that they're making those decisions in isolation of one another. So I think I see our role as a connector to help, you know, in a value based world, the incentives start to align between risk bearing entity and health system. And many times the health system becomes the risk bearing entity fully. And so our goal is to empower providers to understand those things in real time, to manage the complexity for them, only engage them with the information that makes a difference in the decision they're trying to make and ultimately create a better experience for the patient, a better outcome for the patient, and a less burdensome process for the provider organization.Harry Glorikian: So as we all know, I mean, the American medical system is famous for sending patients surprise bills after clinical encounter or an emergency room visit, right. Where a bandage or an aspirin can carry some crazy prices that I've seen. And I'm trying to project onto where you are as a company and where you want to go. I mean, now that you've tackled the rrtransparency in drug pricing, which I would honestly like to see everywhere, because I think I've heard my wife complain all the time when she encounters some astronomical price. Right. Can you imagine trying to tackle or bring greater transparency to other medical costs, such as maybe a surgical procedure or hospital supplies. I mean, is there anything that you've learned about prescription benefits that's transferable to all these other types of care?Kyle Kiser: Absolutely. Yeah. We're already moving beyond prescriptions today and focused on labs, radiology services, generally. And see the dynamics of the payer-PBM end of the market five or six years ago as it relates to pharmacy real time benefit shaping up much in the same way around medical benefits. That payers are thinking about these problems in the same ways and are showing initiative and prioritizing putting this information at the point of care for for all of the reasons that we just described on the drug side are true in many ways on the medical side. So, yes, absolutely. That's where we're headed. And the regulatory tailwinds are there in a new way. Right. If you think about in the last 12 months, there's been more price transparency legislation than in the last 30 years. And that, combined with the no surprise billing legislation, really creates this this kind of pre EOB requirement for each of the stakeholders and they got to solve that problem. And we see ourselves as really well positioned to be a part of that solution.Harry Glorikian: Yeah. I mean, you know, it there was no way. I mean, the Affordable Care Act got put into place and there were certain things in there that just there was no way that you were going to be able to do that without some level of transparency and understanding what's going on.Kyle Kiser: Yeah. Yeah, that's right. But even further, right, before the end of last year there were price transparency regulations for health systems, for providers, for payers. And then the no surprise billing legislation has in it a component that says, you know, before you deliver care, you got to be able to give an estimation of cost. And so all of those things sort of work together from a regulatory perspective to start to drive the market in that direction. So absolutely, it's coming everywhere. It's going to be, it's going to be a part of the way that every health care decision is made in the future. And it's just a matter of time before that's the case.Harry Glorikian: Yeah. It's interesting because I have lots of conversations with, you know, lots of different people. And they I don't think they understand that. If you don't have that level of transparency, you truly don't have a competitive environment, right? You can't make choices because you don't have the information to be able to make that choice.Kyle Kiser: That's exactly right. Without it, there is no marketplace. Right. That's probably overstated. It's without it, it's a dysfunctional marketplace. And with transparency, we will start to see real competitive dynamics emerge. And I'm hopeful for that. Sunlight's the greatest antiseptic.Harry Glorikian: Oh, I totally agree. I mean, for me, it's always been like a walled garden. Like, you know, either you're here or, you know, you're out of luck, right? Because you don't have any information so you can go across the street. So. So. I guess I should be asking. I've probably reached the limit of my knowledge on the subject matter, but like, is. Is there anything I haven't asked you or anything, you know, that you would want to add to the conversation that would be enlightening to the people that are listening?Kyle Kiser: Yeah, well, the only thing I would sort of make sure we reframe a little bit is that this isn't necessarily about price transparency. Price transparency is a component of providing access to care for patients, and that's ultimately what we continually focus on inside of our company, that price is an input. Affordability is an input. Convenience is an input. The ability to actually receive the prescription is an input. We're ultimately trying to make sure that affordability and speed to care lead to better outcomes. And that's an access story, not just a price transparency story. And so that's the only sort of reframe that I'd offer is that ultimately this has to lead to better health, people getting healthier, getting the care they need, being able to afford the medications that they need. And that's the work. And we're going to stop at nothing to make sure that that happens.Harry Glorikian: Excellent. Well, it was great talking to you, Kyle. I wish you great success because, I mean, whenever I talk to anybody, I'm like, I know I could be benefiting from all of this, so I want everybody to be successful.Kyle Kiser: We appreciate the well-wishes and we'll be working hard to ensure that that's the case.Harry Glorikian: Excellent. Thank you so much.Kyle Kiser: All right. Thanks, Harry.Harry Glorikian: Bye bye.Harry Glorikian: That's it for this week's episode. You can find a full transcript of this episode as well as the full archive of episodes of The Harry Glorikian Show and MoneyBall Medicine at our website. Just go to glorikian.com and click on the tab Podcasts.I'd like to thank our listeners for boosting The Harry Glorikian Show into the top three percent of global podcasts.If you want to be sure to get every new episode of the show automatically, be sure to open Apple Podcasts or your favorite podcast player and hit follow or subscribe. Don't forget to leave us a rating and review on Apple Podcasts. And we always love to hear from listeners on Twitter, where you can find me at hglorikian.Thanks for listening, stay healthy, and be sure to tune in two weeks from now for our next interview.

The economic landscape has been changing quite a bit since COVID-19—inflation, the Ukraine-Russia war, supply chain backlogs, etc. And some of these things will obviously affect the PT industry. But exactly how and to what extent? What can be done to alleviate the negative trends? Dimitrios Kostopoulos, P.T., M.D., Ph.D., D.Sc., ECS, of Hands-On Diagnostics and Hands-On Companies, shares with us his view of current and future trends, what may be coming down the line from Medicare, and what can be done to survive the changes.Love the show? Subscribe, rate, review, and share! https://ptoclub.com/

In early May, CMS released the inpatient prospective payment system proposed rule for fiscal year 2023. In this year's proposal CMS introduced several policies aimed at addressing health equity. Among those is a data collection condition that would require a provider to attest that their organization is capturing SDOH measures. Eric Fontana, Vice President of Client Solutions at Optum Life Sciences, has spent much of his career helping health care leaders make sense of data and regulations. In this special Open Mic edition of Radio Advisory, Eric shares his thoughts about why this could be a game-changer for researchers. Interested in sharing your thoughts about health care on an Open Mic? Pitch us your idea by emailing podcasts@advisory.com. Links: The 2023 inpatient proposed rule: What you need to know IPPS Regulations and Notices [CMS website]

Listen to Health Affairs Editor-in-Chief interview Andy Slavitt, co-founder of both United States of Care and Town Hall Ventures and former administrator of the Centers for Medicare and Medicaid Services.Andy is the host of the podcast In The Bubble with Andy Slavitt and recently published the book, "Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response."Currently, more than 70 percent of our content is freely available — and we'd like to keep it that way. With your support, we can continue to keep our digital publication Forefront and Podcasts free for everyone.Subscribe: RSS | Apple Podcasts | Spotify | Stitcher | Google Podcasts

On this episode of Health Care by the Numbers, Kim Holland, Senior Vice President at Signify Health is a guest host and is joined by Tim Gronniger, Executive Vice President at Signify Health and CEO at Caravan Health. During this episode, they discuss the goal that CMMI set in their recent Strategy Refresh to get all Medicare lives and most Medicaid lives into accountable care or total cost of care arrangements by 2030. Kim and Tim share policy takeaways and focus on ambitious goals that set the stage for ACO work in this decade. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Elizabeth Robinson from HAP with information on Medicare! with guest Dione Oliver of Guaranteed Rate. Thanks for listening - I'm Tracey Tucker the Flint Township Economic Enhancement Director reminding you to - Stay Safe, Stay Healthy, Shop Local, Buy Local and Discover Flint Township! Special Thanks to Brilliant Marketing Company for donating the use of B!Roll Studios.

  AHIP certification for 2023 is LIVE! Get the details and learn about Ritter's tool for keeping carrier requirements straight! Read the text version. Register for your FREE RitterIM.com account   Mentioned in this episode:   Contact the Team at Ritter Insurance Marketing AHIP Medicare + Fraud, Waste, and Abuse (MFWA) Training America's Health Insurance Plans Official Website Register for your FREE RitterIM.com account Ritter's Certification Center   More episodes you'll like:   2023 Maximum Broker Commissions for Medicare Advantage and Medicare Part D FAQs about AHIP Start Selling 5-Star Medicare Advantage Plans All Year The Benefits of Joining a Top Insurance FMO What is AHIP and Why Do You Need It?   Articles to Share with Your Clients:   Medicareful Travels: A Senior Guide to All-Inclusive Resorts The Causes and Treatments of Nasal Congestion What is Medicare's Secondary Payer Program?   Ritter Insurance Marketing eBooks & Guides:   The Complete Guide on How to Sell Medicare Advantage Plans The Complete Guide to Client Loyalty and Retention The Definitive Guide to Getting Leads and Prospecting for Medicare Sales   The latest from Ritter's Blog:   FAQs About Selling On-Exchange & Off-Exchange Under-65 Plans How to Check for Your First Looks Lower 2023 Medicare Part B Premium Expected After Reassessment by CMS   Connect on social:   Facebook LinkedIn Twitter YouTube Instagram TikTok Sarah's LinkedIn Sarah's Instagram   Subscribe & Follow:   Apple Podcasts Google Podcasts Overcast Podbean Spotify Stitcher  

June 20,2022 A couple samplings from Medicare for All Explained, a podcast produced by Physicians for a National Health Program (PNHP) and Joe Sparks: Dr. Anthony Spidaro discusses a single payer healthcare system as a public health issue; Dr. Joseph Jarvis advocates for single payer from a conservative's perspective; locally, Dr. Steve Lippman advocates for a single payer system

We know healthy food is good for our body, but evidence shows it's good for our mind too, and the peak body for dietetics in Australia wants nutrition help to be covered by Medicare in mental health plans.

Are you committed to having a tax-planning conversation outside the tax season? The only way to win in the tax game is to have a proactive approach when it comes to tax planning. It's important to be committed to having some kind of tax-planning conversation on any topic, especially with a professional outside of the traditional tax period. In this episode of the Secure Your Retirement podcast, we have Steven Jarvis, a CPA, owner of Retirement Tax Services, the host of Retirement Tax Podcast, and is knowledgeable in tax planning. We discuss the benefits of tax planning and a few ways how you can get intentional to avoid paying more tax than needed. In this episode, find out: The importance of tax planning to avoid the pain of the tax-paying experience. How (QCDs) can lower your taxable income even when taking standard deductions. How doing a QCD can help you pay lower premiums for Medicare. The benefits of the donor-advised fund, allowing lumping of multiple years of charitable contributions into a single year. Why you should consider getting your money into a tax-free bucket according to your tax bracket. The reasons why you should or shouldn't consider doing a Roth conversion. Tweetable Quotes: “Everyone should consider a Roth; it does not mean anyone should do one.”- Radon Stancil “If you have any concerns that tax rates might go up, getting dollars into a tax-free bucket is going to set you up for success.”- Steven Jarvis “The only way we get ahead with tax planning is if we have an intentional approach.”- Steven Jarvis Get in Touch with Steven: Website:https://retirementtaxservices.com/ ( https://retirementtaxservices.com/) LinkedIn:https://www.linkedin.com/in/steven-jarvis-cpa-ba91aa23/ ( https://www.linkedin.com/in/steven-jarvis-cpa-ba91aa23/) Resources: If you are in or nearing retirement and you want to gain clarity on what questions you should be asking, learn what the biggest retirement myths are, and identify what you can do to achieve peace of mind for your retirement, get started today by requesting our complimentary video course, Four Steps to Secure Your Retirement! To access the course, simply visit https://pomwealth.net/3-keys-to-secure-your-retirementlp/ (POMWealth.net/podcast.)

Alan Horowitz is of counsel in the Healthcare practice at Arnall Golden Gregory LLP, and a member of the Post-Acute & Long-Term Care industry team. He is an innovative healthcare lawyer handling complex regulatory issues concerning Medicare providers such as skilled nursing facilities, hospices, and home health agencies. Known for his unique and significant healthcare experience, Alan held clinical, faculty and management positions at major medical centers where he utilized his management skills as well as his background as a registered respiratory therapist and registered nurse. In 1976, Alan formed the first neonatal respiratory care team while at Hahnemann University Medical Center in Philadelphia. Above all, he is most concerned with helping clients run businesses that provide the highest level of client care possible.Visit us at: https://www.unitedpatientsgroup.comFollow our YouTube: https://www.youtube.com/c/Unitedpatientsgroup1Follow us on Twitter: https://www.twitter.com/upatientsgroupFacebook: https://www.facebook.com/UnitedPatientsGroup/

My guest today is a local real estate investor and entrepreneur.  Jon Frantz is not only an expert in business finance and development, capital raising, property management and operations, he's also transforming the Alger Heights neighborhood with several businesses, including Top to Bottom Cleaning Group, Urban Jonny's Salon, and the new and exciting SIP Coffee & Cocktails. Jon shares his early sales experience with Cutco Knives and the importance of that training. He also talks about his first house-hacked 3-unit, and how he had to sell his car in order to buy it. We also dig into the differences between investing in real estate and starting a business, the importance of partnership, and the biggest mistakes he sees new entrepreneurs make. I know you're going to enjoy this conversation with Jon. You can find out more about him through his websites: https://www.frantzconstellations.com https://www.jacompanies.com Today's episode is brought to you by Green Property Management, managing everything from single family homes to apartment complexes in the West Michigan area. https://www.livegreenlocal.com And RCB & Associates, helping Michigan-based real estate investors and small business owners navigate the complex world of health insurance and Medicare benefits. https://www.rcbassociatesllc.com

Many experienced financial professionals are predicting that we'll soon be confronted with a recession. On today's show, we're going to offer up some tips that may help recession-proof your retirement.

Interview originally aired January 15, 2022

1 Due Process Victory! AZ Court of Appeals Sides with NCLA A three-judge panel of the Arizona Court of Appeals ordered the removal of NCLA client Phillip B.'s name from the Arizona Department of Child Safety (DCS) Central Registry of substantiated findings of child abuse. DCS's then-Director had ‘deleted' factual findings and credibility determinations made by an independent administrative law judge (ALJ) who took live testimony in the case. DCS thereby unjustly destroyed Phillip B.'s reputation and career. In a decision that vindicates Phillip B., the Arizona Court of Appeals held: “Because [the DCS] Director's Decision here does not meet the regulatory requirements for a substantiated finding, there is no legal authority for the Director to enter Phillip B.'s name into the Registry.” Mark announces the victory in the AZ Court of Appeals. 2 In NCLA Amicus Win, SCOTUS Rules Against HHS A unanimous Supreme Court has ruled that the Department of Health and Human Services (HHS) violated the 2003 Medicare Act by lowering drug reimbursement rates for specific hospitals. NCLA filed an amicus brief in support of petitioners in American Hospital Association v. Becerra. NCLA agreed with the petitioners' argument that HHS's authority under the Medicare statute to “adjust[ ]” average sales price when calculating reimbursement rates does not include wholesale authority to substitute acquisition costs for average sales price. Mark discusses the amicus victory. See omnystudio.com/listener for privacy information.

The market has fallen into bear territory. But what does that mean for you and your finances? In this episode Jeff talks about ways to deal with the market volatility and what to avoid.

Last week, the Federal Trade Commission launched a formal inquiry into pharmacy benefit managers (PBMs).Listen to Health Affairs' Leslie Erdelack and Vabren Watts discuss the FTC's probe into PBMs and how vertical integration and consolidation may affect patients and health care consumers.Related Links: FTC Launches Investigation Into Major Pharmacy Benefit Managers' Business Practices (FierceHealthcare) A Six-Step Solution To The PBM Problem (Health Affairs Forefront) On Drug Prices, Pharmacy Benefit Managers Are Not The Problem (Health Affairs Forefront) PBM Oversight, Insulin Cost-Sharing Provisions Among Build Back Better Act (Health Affairs Forefront)  Currently, more than 70 percent of our content is freely available — and we'd like to keep it that way. With your support, we can continue to keep our digital publication Forefront and podcasts free for everyone.Subscribe: RSS | Apple Podcasts | Spotify | Castro | Stitcher | Deezer | Overcast

Dr. Jeff Burns talks with Dr. Ron Petersen, Director of the Mayo Clinic Alzheimer's Disease Research Center, about Medicare's recent decision to officially limit Aduhelm (aducanumab) coverage to patients in clinical trials. Read the full article discussed in this interview in the New York Times.

Dr. Ron Petersen, Director of the Mayo Clinic Alzheimer's Disease Research Center, discusses Medicare's recent decision to officially limit Aduhelm (aducanumab) coverage to patients in clinical trials. Read the full article discussed in this interview in the New York Times.

By Amy Goodman & Denis Moynihan Single-payer, or Medicare for All, makes sense in normal times, but we are not in normal times. The global COVID-19 pandemic has ripped the scabs off of so many sectors of our society, exposing and exacerbating inequities and a lethal lack of preparation.

I have been on a mission to figure out why some health systems, particularly in the oncology space but not limited to the oncology space, could manage to mark up the price of infused specialty pharmacy drugs up to 6x. Some employers and patients are paying six times the cost of a specialty pharmacy drug in markup for some already incredibly expensive specialty pharmacy drug at some oncology centers. Read more about this in a study by Roy Xiao, MD, and colleagues. Let's not forget now or ever that financial toxicity is clinical toxicity. This 6x is exactly how financial toxicity is operationalized. Many patients are charged a coinsurance percentage based on their cost of care, after all; and like 20% of 6x is a huge number, it is a huge bankrupting bill for some patients—maybe many patients. That, plus their premiums go up because, of course, their employers are picking up the remaining 80% of that 600% markup. Families are already, on average, paying I think it's $22,000 in premium; and the trend line on that premium growth continues to go up steeply in the 2022-23 projections that I have seen. Bottom line: This 6x is not a victimless modus operandi is my point. But what I wanted to know is how they do it, these health systems. Charging 6x the cost of a super expensive specialty pharmacy drug in markup would seem to require some skill, right? And any time I see a Pandora's box, I have a terrible habit of trying to get in there. Autumn Yongchu and Erik Davis to the rescue. Today's show digs into how some health systems and hospitals stack the odds that no one will notice their 6x markups and just pay the bills. Here's the short version of the playbook, but you'll need to listen to the show for a more robust explanation. First off, keep in mind that while Medicare Part B tells hospitals to charge ASP (average sales price) + 6% (ish) when they buy and bill Medicare patients, there is no such guidance for commercial patients. Commercial insurers negotiate a fee off chargemaster rates, and as we all know, those chargemaster prices are, in general, based on absolutely nothing and are, in general, sky-high. So that's the first thing. The second thing gets into coding. Let me give you the general idea here, but we talk about this in some depth in the conversation to come. As you likely know, hospitals get paid by sending bills with codes on them—procedure codes, for example. We the hospital did this procedure, and our charge for this procedure is $4000—so, here you go. Code followed by dollar amount is shown on somebody's bill or explanation of benefits document. These procedure codes are standardized across the industry for the most part. It's not like every health system and/or payer is making up their own. This standardized set of procedure codes is called the Healthcare Common Procedure Coding System, affectionally known as HCPCS. So, if someone starts talking about a HCPCS code, all it means is that the code comes out of that standard set of codes. Now, J-codes are one kind of code in this common procedure coding system. They are procedure codes that start with a “J.” These J-codes are for procedures involving (usually) specialty pharmacy drugs. A J-code identifies the specialty pharmacy drug that was used in the procedure. So, you'd think it'd be pretty easy to audit a hospital bill, right? You look at the J-code on the bill; you find the ASP, the average sales price, or whatever of the drug; and then you get out your trusty calculator and you do the math on what the markup is. And okay, maybe this works sometimes … but the problem is that so very, very often, the hospital doesn't put the actual drug's J-code on the bill. There's this miscellaneous J-code that doesn't specify the drug used, which is a quite common tactic, it seems. (I learned that in this episode.) Hospital just sticks “Miscellaneous chemotherapy” on a bill with a price after it, and nobody knows what drug was used. Or the hospital will send a bill that just includes revenue codes. I think about revenue codes as the name of the section of the bill. It's like on a menu: There's that section, that headline, that says “Seafood” with a whole list of seafood dishes underneath it. In this example, the Seafood header is like the revenue code; and the J-codes are the actual dishes. Some bills come from the hospital, and all they have on them are the revenue code. There was some seafood. We're not gonna tell you what dish or how much seafood, but yeah, seafood. The only thing we know about seafood is that there was some and it was very pricy. Here's a great example of a bill with some explanations.   The main point here is that how health systems get away, in large part, with charging a whole lot for specialty pharmacy drugs is that their bills roll up charges into these very opaque codes that include lots and lots of stuff that is not broken out. When I interviewed Marshall Allen (EP328) and we talked about his book Never Pay the First Bill, he said step one in getting an accurate and fair bill is to ask for the line item charges—and now that is totally making sense to me and also why this is so vital. Just be aware, if you ask for these breakouts, you will likely get a huge box of hard copies. Check out this photo of a literally three-foot pile of printouts that one patient-turned-artist exhibited at an art show recently that I saw. If you don't have the stamina to sort through all of those pages and pages and pages, you could be subject to 6x or more in markups or billing errors which are all too common and all too expensive. Hospital charges are a huge chunk of any employer's healthcare spend, after all—over half of it in some cases. These are not small potatoes that we're talking about. These are bills that bankrupt patients and make premiums go so high that patients cannot afford to get care.   In this healthcare podcast, as mentioned earlier, we have two guests—Erik Davis and Autumn Yongchu—both from USI Managed Care Consulting and both having spent decades deep in the inner workings of the healthcare industry. And the topic of today's show required that depth of knowledge, for sure. You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis, AAI, CIC, CRM, is senior vice president and principal consultant, managed care and analytics, at USI Insurance Services. He has over 30 years of experience in the insurance and risk management industry. Erik works to create an environment that supports the healthcare risk management goals of an organization while maintaining focus on compliance and financial accountability. He is instrumental in vendor negotiations, data benchmarking, population health strategies, claims analysis, recommendations in plan design, and communication strategies. In this capacity, Erik has been involved with development of rates, payment structures, and recommendations of changes in processes, policies, and procedures. He has a broad understanding of contract analysis, evaluating risk, auditing for correct payment, and structuring of excess loss and pharmacy programs. Erik's experience extends from overall employee benefits consulting to workers' compensation, as well as managed care organizations in Medicaid, Medicare, and commercial contractual risk arrangements. Erik earned his bachelor's degree in economics from Oregon State University. He holds Accredited Advisor in Insurance (AAI), Certified Insurance Counselor (CIC), and Certified Risk Manager (CRM) designations. Autumn Yongchu is a healthcare operational risk consultant at USI Insurance Services. Autumn works with multiple database platforms to examine data for trends and abnormalities. Using investigative querying, medical coding analysis, and report development, she provides resources that help identify cost control opportunities and assists organizations in strategic business decisions regarding the management of healthcare risks. Autumn analyzes and interprets healthcare utilization data, allowing the development of initiatives regarding claim and risk management. This includes identifying fiscal and clinical strategies and providing necessary information to develop, design, and implement management initiatives. Autumn also analyzes trends, assists with insurance underwriting, and adjudicates stop-loss claims. Autumn has an in-depth knowledge of Medicaid and Medicare billing guidelines and payment methodologies. Prior to joining USI, Autumn was a claims auditor and trainer for a managed care organization which serviced over 100,000 commercial, Medicaid, and Medicare lives. Her responsibilities included contract analysis, claims adjudication, ensuring accurate payment, and identifying and recouping errors. 07:33 How do hospitals maximize inpatient bills? 08:05 How can hospitals upcode on specialty pharmacy products? 09:44 “It's really not uncommon to be overbilled and overcharged.”—Autumn 11:11 Why do marked up bill charges actually affect the price commercial payers pay? 12:49 “If your payer's not double-checking … how do you know that fraud's happening?”—Autumn 12:52 “If the payer doesn't have the detail to validate what that drug actually is, then are they really checking?”—Autumn 13:33 Why is it so hard to verify what you're actually paying for on a hospital bill? 16:28 How do hospitals maximize profit with outpatients? 17:12 “Really it comes down to contracts and how [the] contracts are written.”—Autumn 21:54 “There are … silos within healthcare, and none of them actually talk to each other.”—Autumn 24:56 “There are these rules out there, but there are also big loopholes out there.”—Autumn 26:13 How can hospitals maximize payments for Medicare patients on drugs that have been out for a while? 29:30 “We just have a tendency to assume … that Medicare has a rate for everything, and Medicare doesn't.”—Autumn 30:32: EP369 with Keith Hartman, RPh.   You can learn more by connecting with Erik and Autumn on LinkedIn or by emailing them at erik.davis@usi.com and autumn.yongchu@usi.com.   Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How do hospitals maximize inpatient bills? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How can hospitals upcode on specialty pharmacy products? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “It's really not uncommon to be overbilled and overcharged.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems Why do marked up bill charges actually affect the price commercial payers pay? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “If your payer's not double-checking … how do you know that fraud's happening?” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “If the payer doesn't have the detail to validate what that drug actually is, then are they really checking?” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems Why is it so hard to verify what you're actually paying for on a hospital bill? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How do hospitals maximize profit with outpatients? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “Really it comes down to contracts and how [the] contracts are written.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “There are … silos within healthcare, and none of them actually talk to each other.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “There are these rules out there, but there are also big loopholes out there.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems How can hospitals maximize payments for Medicare patients on drugs that have been out for a while? Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems “We just have a tendency to assume … that Medicare has a rate for everything, and Medicare doesn't.” Erik Davis and Autumn Yongchu discuss #specialtypharma billing in #healthsystems on our #healthcarepodcast. #healthcare #podcast #hospitalsystems   Recent past interviews: Click a guest's name for their latest RHV episode! Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong