CRN Healthcare Solutions

09/10/2024

Great seeing the Otolaryngologists of Long Island when I spoke for them at their Dinner Meeting last night in Roslyn.

Michael Setzen, MD of Great Neck, NY (who happened to have performed sinus and septum surgery on my daughter many years ago because he is the best) along with my other colleague physicians from Long Island. We had a great turnout last night.

08/09/2024

For all those who work in healthcare, from my friend, Jennifer McNamara, this is a must see!

06/15/2024

Missed last week's episode of Coding with Christine Hall? Don't worry! Check out what you missed on last week's episode! YouTube:

06/11/2024

Why the Medicare physician fee schedule is sheer madness

Susan Dentzer, MS ~ HFMA

Amid the complexities of U.S. healthcare, there is probably no construct that’s more byzantine than the Medicare Physician Fee Schedule (MPFS) — the program’s elaborate system of paying physicians and other clinicians (including nurse practitioners, physician assistants and clinical psychologists) for more than 10,000 medical services.a

In 2022, the schedule drove about $71.2 billion in payments to physicians under Part B of Medicare, and tens of billions of dollars more in clinicians’ Medicare Advantage (MA) payments, many of which are also based on the fee schedule.b Because the schedule is widely emulated by other payers, including employer-provided plans and commercial insurers, it indirectly influences $600 billion annually in private payments as well.c

The MPFS is emblematic of so-called administered pricing, in which prices are set by some outside authority, such as the government, rather than arrived at by markets. In the MPFS’s case, the creators of this monstrosity include Congress, federal agencies, academics and, ironically, physicians themselves. And because it is explicitly a fee-for-service (FFS) system, it manifests many of the “pathologies” of this form of payment, as the noted Harvard healthcare economist Joseph P. Newhouse, PhD, wrote in his classic analysis Pricing the priceless: A health care conundrum.d

Rarely have the pathologies of the MPFS portended such poor outcomes for the future of U.S. healthcare as they do now.

About the MPFS and how it works

Read more at:

The Medicare Physician Fee Schedule, as a fee-for-service system, exhibits a number of "pathologies" says hfm columnist Susan Dentzer.

05/27/2024

Beware of new Microsoft AI Computers if you work in Healthcare and HIPAA Privacy and Security is critical in your everyday work:

Microsoft AI “Recall” feature records everything, secures far less

04/22/2024

From the NY Times on 4/7/2024

Health Insurers’ Lucrative, Little-Known Alliance: 5 Takeaways
A private-equity-backed firm has helped drive down payments to medical providers, drive up patients’ bills and earn billions for insurers.

Large health insurers are working with a little-known data company to boost their profits, often at the expense of patients and doctors, a New York Times investigation found. A private-equity-backed firm called MultiPlan has helped drive down payments to medical providers and drive up patients’ bills, while earning billions of dollars in fees for itself and insurers.

To investigate this largely hidden facet of the health care industry, The Times interviewed more than 100 patients, doctors, billing specialists, health plan advisers and former MultiPlan employees, and reviewed more than 50,000 pages of documents, including confidential records made public by two federal judges after petitions from The Times.

Here are five takeaways.

The smaller the payout to doctors, the bigger the fees for insurers and MultiPlan

When patients see medical providers outside their plans’ networks, UnitedHealthcare, Cigna, Aetna and other insurers often send the bills to MultiPlan to recommend a payment amount.

MultiPlan and the insurers have a powerful incentive to keep the payments low because their fees get bigger as the payments get smaller.

Here’s how it works.By using MultiPlan’s frugal recommendations, insurers say they are saving employers money. But insurers and MultiPlan also benefit because their fees are typically based on the size of the declared “savings” or “discount” — the difference between the original bill and the amount actually paid.

In some instances, insurers and MultiPlan have collected more for processing a claim than the provider received for treating the patient, the one with the cognitive ability, the one who takes on the risk and the one who is there for the patient, providing the service!

WOW (comment by me, Barbara J Cobuzzi)

UnitedHealthcare, the largest U.S. insurer by revenue, has reaped about $1 billion in fees annually in recent years from out-of-network savings programs, including its work with MultiPlan, according to legal testimony.

Patients could be on the hook for the unpaid bills
Patients have seen their bills rise after their insurers began routing claims to MultiPlan, as providers charge them for the unpaid balance.

Some patients said they have scaled back or ceased long-term treatment as a result. The predicament can be especially punishing for people who depend on out-of-network specialists, including for mental health or substance abuse treatment.

Patients have limited recourse. If they want to sue, they usually must first complete an administrative appeals process, and even if the case goes forward, they stand to collect relatively modest amounts.

Self-funded plans are mostly exempt from state regulation, and the responsible federal agency says it has just one investigator for every 8,800 health plans.

CORRECTION by Barbara J Cobuzzi: (This is erroneous, it is more than "self-funded" plans. It is ALL healthcare plans that come from an employer as part of an employee benefit plan, whether self funded or not. All employee health benefit plans that are part of an employee benefit plan, even if the employee pays 100% of the premiums falls under the Federal Department of Labor and ERISA. Do not accept the lies that insurers give you, telling you that the state regulates the plan, because ERISA regulates all employer benefit plans, unless the employer is a government (ie: county, city, state or federal) or a religious organization (ie: church, mosque, synagogue, etc). )

Some medical providers face big pay cuts
MultiPlan and insurers say they are combating rampant overbilling by some doctors and hospitals, a chronic problem that research has linked to rising health care costs and regulators are examining. But low payments also squeeze small medical practices.

Kelsey Toney, who provides behavioral therapy for children with autism in rural Virginia, saw her pay cut in half for two patients. She has not billed the parents of those children, but said she would not accept new patients with similar insurance.

Other providers said they have begun requiring patients to pay upfront because appealing for higher insurance payments can be time-consuming, infuriating and futile.

Former MultiPlan employees said they had an incentive to lock in unreasonably low amounts: Their bonuses were tied to the size of the reductions.

Employers are charged hefty fees
Insurance companies pitch MultiPlan as a way to keep costs down, but some employers have complained about large and unanticipated fees.

For a New Jersey trucking company called New England Motor Freight, UnitedHealthcare used MultiPlan to reduce a hospital bill from $152,594 to $7,879, then charged the company a $50,650 processing fee.

In the Phoenix area, trustees managing an electricians’ union health plan were surprised to learn that the fees charged by Cigna had risen from around $550,000 in 2016 to $2.6 million in 2019, according to a lawsuit the trustees later filed.

Employers trying to verify the accuracy of insurers’ charges have sometimes faced challenges getting access to their own employees’ data.

Private equity is playing both sides
For years, insurance companies have blamed private-equity-backed hospitals and physician groups for hiking bills and making health care more expensive. But MultiPlan is also backed by private equity.

In Battle Over Health Care Costs, Private Equity Plays Both Sides
April 7, 2024

MultiPlan’s annual revenues have climbed to about $1 billion thanks to its embrace of more aggressive approaches to reducing costs. Its premier offering is an algorithm-driven tool called Data iSight, which consistently recommends the lowest payments to doctors — typically resulting in the highest processing fees.

MultiPlan became publicly traded in 2020, and its largest shareholders include the private equity firm Hellman & Friedman and the Saudi Arabian government’s sovereign wealth fund, regulatory documents show.

The most common way Americans get health coverage is through an employer that pays for workers’ medical care itself and uses an insurance company to administer the plan. Providers in the plan’s network have agreed-upon rates, but out-of-network providers often must negotiate payments.

article shared with me:
https://www.nytimes.com/2024/04/07/us/health-insurance-medical-bills-takeaways.html?ugrp=c&unlocked_article_code=1.jE0.DaLb.XNU6L4IcNcAv&smid=url-share

A private-equity-backed firm has helped drive down payments to medical providers, drive up patients’ bills and earn billions for insurers.

01/19/2024

FDA Clearance Granted for First AI-Powered Medical Device to Detect All Three Common Skin Cancers (Melanoma, Basal Cell Carcinoma and Squamous Cell Carcinoma)

DermaSensor Now Available to Improve Skin Cancer Detection in Primary Care

The Rundown: Health technology company DermaSensor just received FDA approval for its handheld device that uses AI and spectroscopy to effectively detect the three most common skin cancers in real time during office visits.
The details:
• In an FDA study, the device correctly identified 96% of skin cancers, with a 97% chance of correctly ruling out cancer.
• The non-invasive device works by shining light on the skin and analyzing cellular patterns with an integrated AI algorithm.
• DermaSensor said its device will utilize a subscription model, priced at $199/mo for five patients, or unlimited use at $399/mo.
• DermaSensor envisions improving collaboration between PCPs and dermatologists — allowing point-of-care access that can lead to quicker diagnoses and referrals.

Why it matters: DermaSensor's clearance represents a milestone in AI's role in healthcare — potentially revolutionizing early skin cancer detection. While the approval took a whopping 12 years, hopefully, this opens the floodgates for a wave of AI-powered medical innovations in the coming years.

DermaSensor Inc. announces FDA clearance for its real-time, non-invasive skin cancer evaluation system. For the first time, the 300,000 primary care p

01/03/2024

From my friend, Don Self. This is very important to all Medicare Patients:

Today is January 3rd and clinics all over the country are having some Medicare patients come in thinking they still have traditional Medicare - when they do not, as the patient unwisely were duped by one of the televised Medicare plans that replaced Medicare advertised by James T Kirk, Kelsey Gramer, Andy Griffith or the others (that are paid $Millions) .

Some patients are showing up that did intentionally replace their traditional Medicare with a Medicare Replacement (Advantage) plan and are now confused when they find out there is not only a co—pay but also that services must be pre-authorized - or they cannot use the same physician they have been using for 20 years. If you fall into these categories or your loved ones do or If you believe you chose a plan based on inaccurate information and want to change plans, contact CMS.

The following link is an separate article that is informative and also addresses this issue.
https://kffhealthnews.org/news/article/medicare-advantage-deceptive-sales-tactics-federal-crackdown/?fbclid=IwAR2yIs1-755Di8iG8TBytVk06PI1-j6pNKeCW_ln8ZskoyPlpwa4R-WHwRk #:~:text=If%20you%20think%20a%20company,or%20877%2D839%2D2675

Yes - every year for the first few weeks, I get emails from doctors saying a vast number of patients are shocked that they were lied to, deceived or totally confused by people on tv or by folks calling the non phones or by the incredible number of brochures they received in the mail offering to switch them - and yes - they were lied to. Read this article for more information, if you wish.
If you or your loved one was switched without your knowledge (which is illegal for Part C plans to do) contact CMS at 800-MEDICARE, its 24-hour information hotline. If you believe you chose a plan based on inaccurate information given to you (Lies) and want to change plans, contact CMS at the same number above, or your State Health Insurance Assistance Program: www.shiphelp.org or 877-839-2675.

This is a PSA and I have zero hidden agenda. I myself have traditional Medicare and I do not sell insurance and I am not paid by anyone for insurance referrals. I am a consultant to physicians and I'm just trying to warn people about the issue. CMS has announced on their website that by 2030, they plan to have EVERY Medicare patient switched over to commercial MA plans so they will no longer be in the claims business. I do not want to lose my Medicare Part B!

The Biden administration wants to crack down on deceptive or misleading Medicare Advantage and drug plan sales tactics. It’s counting on beneficiaries to help catch offenders.

12/14/2023

12/14/2023
Physician Payment Update

A group of bipartisan representatives, led by Rep. Greg Murphy, MD (R-NC), introduced the Preserving Seniors’ Access to Physicians Act of 2023 (H.R. 6683), which would eliminate the 3.4% Medicare cut for physicians that goes into effect on Jan. 1, 2024.
As you know, physicians are once again facing a cut to Medicare physician payment. If Congress does not act, otolaryngologist-head and neck surgeons are facing a 3.4% cut. These cuts come amidst a 4.6% projected increase in medical practice expenses, due to inflation.

H.R. 6683 was introduced on Dec. 7, so it is imperative that your Representative hears from you directly and that you urge them to co-sponsor the legislation before the Medicare payment cut goes into effect next month. Strong bipartisan support for H.R. 6883 will pressure Congressional leadership to schedule a vote on the bill before the end of the year or include it in a year-end legislative package.

Contact your representative
(https://oneclickpolitics.global.ssl.fastly.net/messages/edit?promo_id=21557 ) and urge them to support the Preserving Seniors’ Access to Physicians Act of 2023! Completing the call to action will take just a few minutes of your time. We also encourage you to share this Action Alert with other patients and colleagues.
A group of bipartisan representatives, led by Rep. Greg Murphy, MD (R-NC), introduced the Preserving Seniors’ Access to Physicians Act of 2023 (H.R. 6683), which would eliminate the 3.4% Medicare cut for physicians that goes into effect on Jan. 1, 2024.

As you know, physicians are once again facing a cut to Medicare physician payment. If Congress does not act, otolaryngologist-head and neck surgeons are facing a 3.4% cut. These cuts come amidst a 4.6% projected increase in medical practice expenses due to inflation.

H.R. 6683 was introduced on Dec. 7, so it is imperative that your Representative hears from you directly and that you urge them to co-sponsor the legislation before the Medicare payment cut goes into effect next month. Strong bipartisan support for H.R. 6883 will pressure Congressional leadership to schedule a vote on the bill before the end of the year or include it in a year-end legislative package.

The link puts you to a site that enables you to send to your congressional representative a message from the American Academy of Otolaryngology / Head and Neck Surgeons (AAO/HNS). I am obviously not a Doctor, so I edited the message and indicated that I am a healthcare consultant and took out the parts that indicated that I am an Otolaryngologist or an ENT or a Doctor. And I added my own message, which I included below.

If you do not work in healthcare, you can delete the entire message from the AAO/HNS and include your own message which can be something like I wrote below.

As a patient, I am worried that fewer and fewer students are selecting medicine to pursue as their careers because the pressure, costs to become a physician when balance with the rewards over their lifetime are not commensurate. Continuing to reduce physician fees in the CMS fee schedule, which for profit insurance companies tie their fee schedules to, inappropriately, while increasing the cost to deliver medical services with the overhead costs associated with HIPAA, Compliance and other administrative heavy initiatives has caused medicine to become a losing advocation. Where will our care givers come from in the future?

12/13/2023

Effective ENT Coding Strategies Can Stem Losses from Physician Fee Schedule Cuts

The Physician Fee Schedule Final Rule that the Centers for Medicare and Medicaid Services released November 2 brings two unwelcome payment cuts for otolaryngologists. The cuts aren’t a surprise, but they’re still a disappointment.

Please note that congress us considering reversing the reduction in the conversion factor for 2024 and has a last minute bill to do this pending in congress right now, so the fees may rise a bit before the year starts on January 1st. Also note that this has been done over the past 23 years, the conversion factor drops and last minute, congress intervenes with a bill to reverse that reduction in the 11th hours.

Effective ENT Coding Strategies Can Stem Losses from Physician Fee Schedule Cuts %

12/09/2023

Every year over the past 20+ years, the budget has a cut to the Medicare conversion factor and at the 11th hour as we are about to see the payment for Medicare services be cut for the upcoming year, Congress passes a one year halt to the reduction to the conversion factor, keeping the Medicare fee schedule. And everyone breaths a sigh of releif.

But tell me this. If the conversion factor in 2024 is around the same as it was at the beginning of the Millenium, are costs the same, is the cost of labor, cost for malpractice, cost for supplies, cost for rent and all the other costs of running a medical practice, have they been stable over the past 24 years? the answer is NO. They have continued to rise, rising the cost to practice medicine.

So, doctors should be grateful that Congress kept the conversion factor stable and unchanging, but that has been a cut in pay year over year. The conversion factor should be increasing, not staying the same and defiantly not dropping each year. Doctors income have been dropping. They don't want their children to go into medicine, the pipeline of doctors entering medicine is not sufficient to fill those who wlll be retiring. Why? Because doctors are not appreciated, they are underpaid, accused of committed fraud when simple mistakes are made and are finding that it is just not worth pursuing this area for a career. Our children and grandchildren need to worry if they will have enough doctors to care for them in the future.

https://www.ama-assn.org/practice-management/medicare-medicaid/new-year-s-resolution-congress-cancel-medicare-pay-cut?utm_source=facebook&utm_medium=Social_AMA_Paid&utm_campaign=medicare_cancel_cuts_meta_pl01&utm_content=non-member_phys-res&utm_term=cancel_the_cuts%3A_x&utm_id=6573aba1aaac7f6a236064dd&utm_effort=effort_code&fbclid=IwAR1uCQe51IQcgkoU10cYWNL227ScKE3Ptgu7z8AtD7BCwhpKvuX9ZBg0mrY

The AMA's fully behind new House bill to cancel the entire 3.37% Medicare physician pay cut that’s set to start Jan. 1 and threatens access to care.

12/01/2023

Don Self and Karlene Dittrich gave a terrific webinar yesterday updating the 2024 CMS final rule for the upcoming year. And Karlene provided such wonderful information about the rules for Medicare Advantage, what they try to get away with and what they are really allowed to do, as spelled out in the LAW. And giving us the law so that we can call them out, using the LAW to hold them accountable. This 2 hour webinar, worth 2 AAPC and AMBA CEUs is so worth your time to get and listen in. It is now available to anyone interested in it via ON-Demand. To get it and check it out, go to:

This 2 Hour On-Demand (on-demand means you can access it from your office online and allow your staff to watch it as often as you wish) webinar is probably one of the most educational webinars we have ever taught. Not only do we discuss in detail some of the 2024 Medicare coverage changes in 2024, b...