Terry Loftus

Managed Care Negotiation Best Practices - 2025, Class 2. Negotiating Targets and Rebalancing •Know the facts, not the nonsense the insurance cartels and the academics/think tanks report. According to Millman, national commercial reimbursement rates for states range from 136% of Medicare to 266%. You are being underpaid if your rates are below the national average and/or below the average for your state. https://lnkd.in/gJn8xF6y •The average commercial inpatient reimbursement for each state ranges from 152% of Medicare to 261%, with a national average of 202% •The average commercial outpatient reimbursement for each state ranges from 137% of Medicare to 357%, with a national average of 252%. Note: these rates apply to ASCs as well •The average commercial professional reimbursement for each state ranges from 115% of Medicare to 252%, with a national average of 147% - Health systems need to do a better job negotiating professional rates for their affiliated physicians. •Again, the rates you NEED are based on your mix, i.e., Medicare, Medicaid, Commercial, and Self Pay, and the management effectiveness and efficiency of your organization – it is a straightforward calculation •Like hospitals, the insurance cartels must publish their rates. However, they have made it very difficult to analyze their files. If you want assistance with a local rate comparison, contact John and Pete at After Transparency https://lnkd.in/gHDVBEtS •You can’t fight gravity; GI, Orthopedics, Imaging, and several other procedure-based specialties are (and should be) moving to the outpatient setting. Counting on HOPD rates for these outpatient services is a fool’s errand. •Rebalance the commercial fee schedule so that service revenues migrating to the freestanding outpatient setting are priced below traditional HOPD rates but significantly higher than the commoditized rates being offered by the insurance cartels (i.e., At a minimum, target rates of at least 200% of the outpatient Medicare fee schedule) •The revenue reductions in the outpatient rates should be rebalanced to hospital-centric services such as neurosurgery, ED, and NICU. Ultimately, your organization must base its commercial pricing on:  Revenues-Expenses= Survival So it goes n8 Stay tuned for Class 3 - Preparing for the Unwillingness of the Insurance Cartels to Pay Physicians and Hospitals Fairly #hospitals #healthsystems #healthinsurance #healthinsurance

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☝ Don't Miss the Application Deadlines for the ACO Primary Care Flex Model! CMS is accepting applications for the ACOs Primary Care Flex Model until August 1, 2024. Interested organizations must apply as new or renewing ACOs to the Medicare Shared Savings Program (MSSP) by June 17, 2024. The ACO PC Flex Model will launch on January 1, 2025, and run for five years. Low-revenue ACOs participating in the Shared Savings Program can apply to the ACO PC Flex Model. This innovative model aims to increase the number of low-revenue ACOs and enhance primary care payment through a Prospective Primary Care Payment (PPCP) option, shifting payment from fee-for-service to a predictable, monthly payment. 💲 Enhance primary care payment and innovative care delivery  📉 Narrow Disparities in health care outcomes  🔻Reduce program expenditures while preserving the quality of care  💪 Strengthen participation incentives for new and low-revenue ACOs 💰 Base Rate and Payment Enhancements  💴 One-time Advanced Shared Savings Payment Health Equity Strategy to drive accountable care and advance health equity #ACOPrimaryCareFlexModel #HealthcareInnovation #PrimaryCare #AccountableCare #Medicare #HealthEquity #SustainableHealthcare #ValueBasedCare #VBC #RiskAdjustment #PPCP #SharedSavings #CMS https://lnkd.in/gmiKZsHM

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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The Defense Health Agency (DHA) has awarded 11 companies positions under the unrestricted vendor pool of a potential 10-year, $43 billion follow-on contract to provide medical staffing support services for U.S. military health care facilities. The Department of Defense said Wednesday Medical Q-Coded Support and Services-Next Generation is a multiple-award, indefinite-delivery/indefinite-quantity contract that calls for contractors to recruit, qualify and provide qualified medical contract personnel to support direct patient care and other health activities at DHA hospitals and clinics across the U.S. and its territories. The performance period will kick off in June and run through the end of May 2034. The awardees are: Decypher Health Services, Epic Government, KBR (NYSE: KBR), Loyal Source Government Services, Luke & Associates, Matrix Providers, Optumserve Health Services, Spectrum Healthcare Resources, The Arora Group, U.S. Got People and Vesa Health & Technology.

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🌟 Whether you’ve determined now is the time for you to begin the process toward FACHE or you’re still deciding, the next stop on your journey is our FACHE Overview Webinar. This webinar is free for you to attend but it requires registration. Learn more and save your place here: https://bit.ly/3MkxxT8

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Measuring Quality of Care Quality matters. Better health for everyone should be America’s goal. Where you live and receive your healthcare services makes a difference in your health.   Fortunately, objective understandable quality metrics are now easily available at https://lnkd.in/eVQyZ2E6. This easy-to-use website created by the federal government to help potential patients facilitate comparisons among hospitals is based on a variety of the more than 100 measures CMS publicly reports, divided into 7 measure groups or categories: Mortality, Safety of Care, Re-admission, Patient Experience, Effectiveness of Care, Timeliness of Care, and Efficient Use of Medical Imaging. Adding rationality to decision-making in determining where to go for care has the added benefit of improving performance for all hospitals because every healthcare system will have the extra motivation to improve its “grades.”   Better performance also translates system-wide to fewer complications, decreased waste, and lower costs. All these attributes contribute to a healthier America and the ability to transfer resources previously regarded as “waste” in healthcare to other worthwhile endeavors such as education, infrastructure, safety, and environmental protection.         Healthcare is the largest industry by far in America, consuming 18.3% of the GDP at $4.5 trillion dollars and growing. If the U.S. healthcare industry were considered a country, it would be the fifth largest in the world behind the U.S., China, Japan, and Germany. U.S. healthcare is larger than the United Kingdom. U.S. healthcare perennially ranks last in healthcare of the eleven most developed nations.     Healthcare systems living off a past reputation and perceived greatness, embellished and polished by extensive marketing, are no longer rational, effective, or fair to a naïve, stressed sick person. The most venerable institutions are now the most vulnerable.   Clear metrics such as heart failure, heart attack, pneumonia, and post-operative mortality rates objectively differentiate potential outcomes based on where you go for care. All this data is adjusted for age and severity of illness and, although the system is not perfect, it is the best we currently have, with all institutions having the same grading system.   Additionally, and arguably, even more important than being a repair shop, alert healthcare systems should be focused outside the four walls of their institutions. Sadly, our nation’s life expectancy has decreased in the last few years. This decline hasn’t happened since 1963.   Life has changed. Where you get care matters. Do your homework and add to your life expectancy. America can have better care for everyone now using accessible digital transparency.

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Join Eric Lucas, Jonathan Mason & Georgia Green, MS, CHFP for a webcast on 8/27 - Medicare Regulatory Update: 2025 IPPS Final Rule. We’ll discuss the latest updates for hospitals and cover topics including an evaluation of the IPPS final rule key areas, reimbursement shifts and data trends identified in the IPPS final rule data, and next steps and factors to consider because of the final changes, including the mandatory TEAM model. #healthcare #hospitals

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🔩 Q: What is a Bolt on healthcare benefit? ✅ A: Great question! Self-funded ERISA-governed plans may add on OPTIONAL services to provide more options for members and potentially save more time and money for both plans and members. We call these "bolt-on benefits" in the industry. Here are some examples, and even focused examples on #prescriptiondrugs and #pharmacy: 💊 -On site or near site clinics - that can provide quick appointments for members to get in to the doc or provider when their primary care providers are not available. At these clinics, members can obtain many drugs at these on site or near site clinics at a discount or even free to get them started and up to 100% of the drugs could be charged back to the plan. 💊 -Canadian drug importation programs - patients are allowed legally to personally import drugs with several stipulations (not biologicals, not controlled substances). I will reserve my personal opinions on these Canadian programs for now, but just know that they can be another option for members. 💊 -Cash pay on prescriptions and applying the cost to deductibles and OOPs - especially for the 1/3 of plans that are High Deductible Health Plans (HDHPs) - your plan, if you have a savvy consultant or broker, can set up a program to allow those with HDHPs to apply their receipts to their deductibles and out of pocket accumulators at the beginning of the plan year when patients have to pay out of pocket. You MUST ask your broker, however, if they can set up this option for your plan with the medical carrier, and show a clear pathway at open enrollment for members on where they may turn in their receipts to apply to their deductibles. 💉 Example: 1/1/25 is right around the corner and 70% of plans' accumulators will reset. With the Team Cuban Card, for example, people may pay cash of $748+ cash price with Yusimry, an adalimumab biosimilar, (https://lnkd.in/g5gJz_Mf) or they can purchase a more expensive option on their drug formulary. Why not take advantage of better cash pricing and rewarding the member for finding it and applying it to the deductible? 🛑 Now that the breach of fiduciary lawsuits have arrived, considering bolt on benefits is/are another critical component for plans to explore. If you offer your members options, you're demonstrating that one way your plan is meeting their fiduciary obligations. Maybe all these won't work for your plan.....but you miss 100% of the shots you never take. #pharmacybenefits #pharmacy

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We all know managed care was a scam for the corporatization of health care.. it has cost billions of dollars to adapt to the insurers wishes - which was aimed at maximizing profits. It is not hard to realize that taking care of people is not the same as building cars. The attempt at controlling surgical time is just another idiotic attempt to make/keep more money. So why not send out that balloon and see if it gets shot down. And now to waste the time of the Congress. With any luck positive changes will and should occur on how health care financing is done in the United States. Let us hope so. Bottom line - what a stupid arse idea -

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Hospital Chargemaster Explained... is a 13,200% Markup Reasonable?!? The Hospital Chargemaster is a list or database of hospital supplies, medications and services (e.g. 15-min of operating room time) and their associated prices billed to insurance, Medicare and Medicaid. The Chargemaster includes: 1) Department number (unique to each hospital) 2) Charge Code (unique to each hospital) 3) Supply, Medication, Service Description 4) Revenue Code (standardized across hospitals) 5) CPT/HCPCS Code 6) Price (Billed Charges) Unfortunately, each insurance company, Medicare and Medicaid plans accept different combinations of Revenue Codes and CPTs codes... so a combination that may work for Blue Cross will be denied by Cigna. Therefore, hospitals are not told by insurance companies which combinations to use, so they have to just guess and go through a billing process of trial and error. Hospitals have no rational basis for the prices they charge on the Chargemaster. For example, the medication Oxytocin was marked up from a cost of $0.02 to a price of $264 billed to the insurance company... a 13,200X markup. Even with a 50% discount from the insurance network, that is still at 6,600X markup!! Final seconds of video and sources at AHealthcareZ YouTube Channel. #HospitalPrices #PriceTransparency #Chargemaster #Healthcare #HealthInsurance #HealthcareCosts

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The ability to be compensated for work carried out in the healthcare space has become increasingly difficult and complicated. It is imperative that our industry remains current on trends, changes, and projected challenges, to ensure our readiness in combatting them. The ambulance industry of today is far different from when our organization first opened in 2010, and we have continuously evolved to meet these challenges head-on. This will remain a big talking point for years to come, and/or until significant changes are made to the benefit of providers. In healthcare, you expend a great deal of capital to provide a service, and in return, you "hope" for reimbursement. Try doing that at a local restaurant - order and eat your food, and tell the staff you MIGHT come back with payment in 90-120 days. Let's see if you make it out of there without cleaning some dishes on your way...

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With a continued rise in health care costs, health systems are pressured to find ways to manage expenses while maintaining the quality of care. Take a look at the five guiding principles, listed in this Becker’s article, to help health systems design effective physician incentives for cost control. #WeatherbyHealthcare #Beckershospitalreview #Locums

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SCAN Health plan's successful suit of the CMS over an obscure provision (Tukey outlier detection) in the regulations will result in ~250 million dollars changing hands from the CMS to SCAN health plan. Got me wondering about what the healthcare system is getting out of measuring quality. So I took a look at two of the common healthcare quality measurement systems, HEDIS and STARs. I broke all the measures into six categories: *Screening/Assessment/Evaluation *Survey *Immunization/Vaccine *Medication/Adherence *Biometric Control *Non-Screening Procedure or Service The first two are obviously pure process measures (did you screen a patient or provide a follow-up visit). The next two reflect clinical patterns but do not measure outcomes (e.g. are the medications working). I would argue the last two reflect actual clinical outcomes or impacts. HEDIS MY 2024 broke out as: *Screening/Assessment/Evaluation - 43% *Survey - 6% *Immunization/Vaccine - 3% *Medication/Adherence - 25% *Biometric Control 6% *Non-Screening Procedure or Service - 16% STARS: *Screening/Assessment/Evaluation - 28% *Survey - 44% *Immunization/Vaccine - 2% *Medication/Adherence - 19% *Biometric Control 5% *Non-Screening Procedure or Service - 2% Most of what the healthcare system pays for in terms of quality is Medication Adherence and Screening. I have long advocated for using episodes of care to help improve both financial incentives and quality. Quality is easier to measure within a specific episode of care, especially when using Patient-Reported Outcomes. As a comparison below is how the new Enhancing Oncology Model Quality Measures break out: *Screening/Assessment/Evaluation - 14% *Survey - 29% *Immunization/Vaccine - 0% *Medication/Adherence - 14% *Biometric Control - 0% *Non-Screening Procedure or Service - 43% Still room for improvement. I've seen some very interesting work done by Patient Discovery and others around patient reported outcomes for cancer. I'd like to see more of this implemented in both CMS programs and private ACO initiatives. Important to think about what we are paying for in quality measurement.

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For part of your fiduciary duty, self-funded plans, you should be asking your carriers about #medicaldrug rebates, or under Medicare, these are considered "#PartB" drugs. These are not drugs you pick up at the corner drug store. These are the drugs that are infused as an outpatient at an infusion center, doctor's office, or even sometimes at home. Chemotherapy, drugs like infliximab, or any drug that you need to have infused are likely in the medical plan benefit, NOT the pharmacy plan or benefit. And, spoiler alert - they're often the most expensive drugs to hit plans....ever. ✅ The next time you're with your medical carrier, ask them about medical drug rebates. ✅ Then ask them about medical drug rebates as they apply to your plan, specifically. ✅ Last, ask them when you should be expecting a check on your medical drug rebates. If you get South Park blank stares, that means you're on to something. Keep asking....hold them accountable. There ARE medical drug rebates, and if your plan is paying for medical drugs, your plan should be getting drug rebates back. #pharmacy #medicaldrugs

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Want to know exactly what Medicare will pay your hospital for a specific admission and the impact a CDI query will have on the case? Google your hospital's "CMS provider number" -Systems may use the same number for multiple hospitals so you might need to dig a little Go to this website: CMS.webpricer.gov and click on "Inpatient PPS" Enter the following: Your hospital's provider number that you Googled Admit & discharge date: make them up to a recent time period Total charges: put 10K if unsure, it won't matter except for outlier cases Covered days: put enough days that cover the length-of-stay DRG: Google "MS-DRG Relative Weight table 5" to get a list of all DRGs Click "Estimate" and you'll see your hospital's payment on the right. You can also scroll down and see your hospital's "cost-to-charge ratio", which is a factor in outlier payments. You can click "Edit Claim" and enter higher charges if you want to see when outlier payments start to kick in or try different DRGs If you want to see the impact of a query that takes a case from a "W/O CC/MCC" (without complication/comorbidity, major complication/comorbidity) to an "MCC" (major complication/comorbidity), enter the MS-DRGs that go with each of those, so DRG 379 for w/o cc/mcc and DRG 377 w/MCC in the GI bleed examples in the slides. The attached slides show a snippet of the CMS relative weight table with GI bleed highlighted to show you the different relative weights of the three severity levels for that DRG. Other DRGs may have just one or two severity levels Next slide is a snapshot of the CMS CC/MCC list with "viral pneumonia" highlighted as a major complication/comorbidity (MCC) Last two slides show you how the payment is calculated for a hospital (UCLA in this case) for the GI Bleed MS-DRG and the impact of a query for "viral pneumonia" that increased the severity from a "WO CC/MCC" to "W MCC" This isn't just for adult patients. There are 12 states that pay Medicaid by MS-DRG and plenty of commercial payers in every state that pay by MS-DRG. Contact Pediatric Resource Group (PRG) to help you develop or optimize CDI for your pediatric/neonatal patients. Don't have peds? We have an adult consulting division as well called Physician Resource Group (PRG) #CDI #revenuecycle #hospitalfinance #MSDRG #CFO #clinicaldocumentation

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California Faces the Largest (current) Nurse Shortage in the U.S. States like California and Texas are facing the largest nurse shortages per capita, according to Becker's Hospital Review. This stark disparity highlights the importance of regional recruitment strategies in healthcare staffing. How is your organization addressing these geographic challenges to ensure quality patient care? https://lnkd.in/g9BEqv-t #HealthcareStaffing #TalentAcquisition #NurseShortage

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➡️ Whether you’ve determined now is the time for you to begin the process toward FACHE or you’re still deciding, the next stop on your journey is our FACHE Overview Webinar. This webinar is free for you to attend but it requires registration. Learn more and register here: https://bit.ly/4fVBYRC

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I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

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