In this episode of The Strain, Jennifer Brown, General Counsel at Progressive Emergency Physicians, joins hosts Eliot Listman and Jim Blakeman to delve into the complexities of healthcare litigation and revenue recovery through the lens of the No Surprises Act. Jennifer shares insights into navigating the Independent Dispute Resolution (IDR) process under the NSA, securing in-network contracts, and managing payer disputes. The discussion covers key strategies for tackling payment denials and balancing payer relationships. Jennifer also offers insight into the intricacies of batching claims efficiently for IDR.

00:00 – Introduction

01:07 – Host and guest introductions: Eliot Listman introduces co-host Jim Blakeman and Jennifer Brown, General Counsel at Progressive Emergency Physicians. Jim describes his travels throughout Europe.

02:10 – No Surprises Act (NSA): Discussion on the NSA and challenges with the IDR process.

04:26 – Background on Progressive Emergency Physicians and its in-network strategy.

05:24 – Jennifer shares her experience balancing legal responsibilities with revenue cycle management after the NSA's introduction.

06:30 – Success with signing contracts using IDR: Jennifer attributes wins to her deep understanding of the regulations.

07:49 – Handling payer pushback: Negotiating reimbursement rates and resolving contract disputes.

09:03 – Dealing with denials and audits: "At the end of the day, it requires a ton of babysitting from your revenue cycle management partner."

10:00 – Tackling out-of-network claims through the IDR process.

11:03 – The impact of IDR success on payers' willingness to contract: "You must’ve built a pretty good plane to yield these guys willing to contract."

12:15 – Importance of transparent communication with hospital partners to maintain contracts.

13:19 – Jennifer’s key strategy: "Over-communicate, can’t go wrong. Persistence is key. Communication is key."

15:30 – Challenges with batching claims: Navigating complex rules across states like New York.

17:30 – Learning through trial and error: "It’s trial and error. If the IDRE says these claims are improperly batched, you resubmit them."

20:30 – Practical tips to get payers to pay post-IDR wins: "More organized you are, the quicker you’re going to get paid."

23:00 – Discussion on pending regulations and legislation to improve IDR compliance.

25:05 – Overview of the Texas Medical Association (TMA) cases challenging the NSA’s payment methodologies.

28:30 – Challenges with insurance-driven methodologies like the Qualifying Payment Amount (QPA).

30:12 – Payers’ lobbying influence on policy and the reality of insurance premium increases.

32:15 – Litigation trends: The significance of recent legal decisions on the IDR process.

34:30 – Jennifer discusses her work with EDPMA to address issues plaguing the No Surprises Act.

36:37 – Closing remarks

The Strain is sponsored by Allia Group: Financing Healthcare Litigation

Connect with Eliot

Connect with Jim

Connect with Jennifer Brown

Follow Allia Group on LinkedIn

Visit Allia Group

Hosted on Acast. See acast.com/privacy for more information.

Episode Description:

This episode of "The Strain: Winning the Battle with Big Health Insurance" features guest Patrick Velliky. Patrick is the VP of Government Affairs for Envision Healthcare, one of the largest hospital-based physician groups in the country. In this episode, Patrick shares his insights on the impact of the No Surprises Act through the lens of policy, a space in which every problem is the product of an incentive or motivation. Learn how physicians can make a difference by reaching out to their representatives - every small action cumulatively adds up to equal real change. Discover the challenges physicians face in IDR due to a lack of enforcement mechanisms and payer loopholes, the misalignment of incentives in the industry, and potential solutions to enhance the process of resolving claims. Join us for this deep dive into the complexities of out-of-network claim processing and challenges faced by healthcare providers in the post-NSA world!

Timeline:

00:00 - 03:12: Introduction to Patrick Velliky of Envision Healthcare. Patrick shares his journey from the payer side of the table to provider-side, enabling him to understand how each party approaches important issues. Every problem in the policy space is the product of an incentive or motivation, according to Patrick.

03:12- 05:56: Discussion of policy nuances between hospitals versus physician groups and the importance of bringing providers’ perspectives and stories to Capitol Hill.

5:56 - 6:57: The story of Patrick writing Senator Arlan Specter’s floor eulogy for Ted Kennedy.

6:57 - 13:25 - Discussion of the different ways providers can be effective in advocacy, Envision’s recently launched Advocacy Champions Program, and Patrick’s advocacy work both with societies like EDPMA and ACEP, and Envision.

13:25 - 16:21 - Discussion about the state of underpayments pre-to-post NSA. Reflection on challenges posed by the fact insurers are paid in advance, but providers are paid in arrears. The seemingly “interminable” IDR process.

16:21 - 20:10 - How did a good law like the NSA go so downhill? The team discusses policies which cut providers out of fair payment opportunities. Patrick suggests the aim to reduce federal spending led to an overshooting of goals and negative impacts on providers' financial stability.

20:10 - 21:45 - The conversation shifts to concerns about vertical consolidation within health plans, with insurers becoming the largest employers of physicians. Attention in the policy space is needed to address the consequences of this consolidation.

21:45 - 26:32 - Reflection on downcoding challenges in emergency medicine. Patrick discusses the need for more enforcement mechanisms on payers to ensure the effectiveness of the NSA.

26:32 - 29:53 - Eliot and Patrick discuss the recent New York Times expose about Multiplan. The conversation highlights the predatory nature of compensation schemes like shared savings, creating misalignment of incentives between employers, third-party administrators (TPAs), and healthcare providers.

29:53 - 38:08 - Patrick discusses ways to achieve better reimbursement, challenges in negotiating reimbursements for the ED and with ERISA plans, and highlights the importance of ensuring that clinicians are valued by payers to the same extent they are valued societally. The team also discusses challenges and costs associated with navigating different state IDR models.

Hosted on Acast. See acast.com/privacy for more information.

This episode of "The Strain: Winning the Battle with Big Health Insurance" features Ron Howrigon. Ron is the president and CEO of Fulcrum Strategies, a healthcare consulting firm specializing in payer contract negotiations for physician groups. In this episode, Ron shares his surprising journey from working for a major insurer to starting a consulting company to help physicians after an eye-opening moment during his son's birth you won’t want to miss. Ron discusses the challenges facing emergency physicians, including contract terminations and reimbursement cuts, exacerbated by the No Surprises Act. He emphasizes the need for physician involvement in healthcare reform and highlights the perverse incentives in the insurance industry that prioritize profits over patient care. Discussion of Ron's books, "Flatlining" and "Clear: Reforming Healthcare to Save the US Economy," provides further insights into the complex issues plaguing the healthcare system and offers suggestions for reform.

Healthcare providers are experiencing a massive financial strain brought on by big health insurers.

That’s why we are embarking on a journey to unravel the complexities, challenge the status quo, and find solutions to the economic challenges that have been plaguing physicians, hospitals, and others for far too long.

The Strain is hosted by Eliot Listman, CEO of Allia Group and pioneer of a healthcare litigation finance model that challenges insurer underpayments, and Jim Blakeman, an industry leader and passionate advocate for appropriate reimbursement for healthcare providers for over 40 years.

The Strain also features influential voices in healthcare and finance.

The Strain is sponsored by Allia Group: Financing Healthcare Litigation

Connect with Eliot

Connect with Jim

Connect with Ron Howrigon

Follow Allia Group on LinkedIn

Visit Allia Group

Do you have insights into the challenges facing physicians and patients in today's healthcare landscape? We want to hear from you!

Join us in shaping the conversation around healthcare economics and advocating for fair and sustainable practices in medicine. Email elistman@allia.group to get in touch with The Strain Vidcast team.

Hosted on Acast. See acast.com/privacy for more information.