QPA and the No Surprises Act

[GassYous]

Not quite 😉. It was actually a 3day total hospital stay including 1 night in ICU. Liver must be over $1mil.

Just the preop workup for a liver is probably a mil

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[anbuitachi]

wow high deductible plan. and wow surgeon billed way more than anesthesiologist

 

[anbuitachi]

i dont understand why anesthesiology insurance pay has to be so complicated. with time units and all.
why cant anesthesiologist billing be exactly the same as surgeons if the surgery requires anesthesia?

eg; if lap appy surgery bills for 10000 for surgeon, then bill 10000 for anesthesiologist.

 

[nimbus]

wow high deductible plan. and wow surgeon billed way more than anesthesiologist

Even though it’s called a high deductible plan, I don’t pay anything out of pocket once I hit $3k. So not really that high.



Fwiw here’s the surgeon charges and collection:

I’m sure a lot of the collections for both the surgeon and anesthesiologist goes to the “dean’s tax” since they are both in academics.



This was the hospital charges.

I was lucky to have health insurance. I don’t know how a waitress or drywaller without health insurance would deal with something like this.

 

[GassYous]

Even though it’s called a high deductible plan, I don’t pay anything out of pocket once I hit $3k. So not really that high.



Fwiw here’s the surgeon charges and collection:

View attachment 350137


I’m sure a lot of the collections for both the surgeon and anesthesiologist goes to the “dean’s tax” since they are both in academics.



This was the hospital charges.View attachment 350138


I was lucky to have health insurance. I don’t know how a waitress or drywaller without health insurance would deal with something like this.

Actually insurance is the only reason that hospitals can bill like this. Do you think 99% of people can pay 80k for surgery out of pocket? The 300k is sheer fantasy too

 

[Luvssjeter]

Yes. As far as I know they are still in-network. It’s an academic regional referral center (one of the Univ of Ca hospitals). Not PE. Surgeon received about $10k for the procedure. (Both surgeon and anesthesiologist are actually salaried but the amounts described are for their professional fees). Total hospital charges were $290k. The hospital accepted about $70k from the insurance company. I had already met my deductible earlier in the year and paid nothing out of pocket.

Academic regional center would be tough to kick out of network based on the fact they are probably negotiating both surgical and anesthesia and many other specialities together. Could be an all of nothing by the hospital. Like you can’t screw anesthesia because we will just take away the thoracic/ cardiac /transplant/pediatric surgeon/interventional cards/EP etc…the insurance company is screwed when it’s members are like I need an afib ablation can’t find an EP doctor or lung mass can’t find thoracic. You guys get the point….this rate for this center makes sense.

And yes, the purpose of this law was to decrease the ability of private equity to obtain higher rates. They ARE supposed to post ALL contracted rates as per the law for all groups in your area for transparency BUT UHC got an extension since they said there was too much data…it is supposed to be enforced by HHS OR CMS starting in July as far as I know. You will know what the academic center gets relative to what your group gets as well as what PE gets…Atleast that’s what is supposed to happen. That’s supposed to be the checks and balance to the QPA…

I’ve done my share of plastics…I’ve heard offers: from 200-300/hr. These are elective and usually healthy patients. Hard to compare this with A.fib ablation in Cath lab or even a total jt where you’re doing a block. But, sure I wish we could just charge cash and do a square swipe in preop.

 

[mtbtx]

Academic regional center would be tough to kick out of network based on the fact they are probably negotiating both surgical and anesthesia and many other specialities together. Could be an all of nothing by the hospital. Like you can’t screw anesthesia because we will just take away the thoracic/ cardiac /transplant/pediatric surgeon/interventional cards/EP etc…the insurance company is screwed when it’s members are like I need an afib ablation can’t find an EP doctor or lung mass can’t find thoracic. You guys get the point….this rate for this center makes sense.

And yes, the purpose of this law was to decrease the ability of private equity to obtain higher rates. They ARE supposed to post ALL contracted rates as per the law for all groups in your area for transparency BUT UHC got an extension since they said there was too much data…it is supposed to be enforced by HHS OR CMS starting in July as far as I know. You will know what the academic center gets relative to what your group gets as well as what PE gets…Atleast that’s what is supposed to happen. That’s supposed to be the checks and balance to the QPA…

I’ve done my share of plastics…I’ve heard offers: from 200-300/hr. These are elective and usually healthy patients. Hard to compare this with A.fib ablation in Cath lab or even a total jt where you’re doing a block. But, sure I wish we could just charge cash and do a square swipe in preop.

Personally I’m very interested how the QPA is derived, who manages this data and where/how it will be published. Will be key to how this plays out.

What you describe for plastics is pretty much what I do. It would not be too crazy to adapt cash prices to the general public for negotiation and education purposes.

 

[linkin06]

https://www.courthousenews.com/wp-content/uploads/2022/02/payment-disputes.pdf

Court Agrees With Physicians' Arguments in Federal No Surprises Act Rule Case​

Statement by Diana L. Fite, MD, Texas Medical Association (TMA) immediate past president, in response to the U.S. District Court for the Eastern District of Texas’ ruling on TMA’s motion for summary judgment in its lawsuit opposing federal regulatory agencies’ unlawful approach to dispute resolution under the No Surprises Act.

"TMA is pleased that the court granted its motion for summary judgment in its lawsuit challenging the federal agencies’ unlawful approach to resolving disputes under the No Surprises Act. This decision is a major victory for patients and physicians. It also is a reminder that federal agencies must adopt regulations in accordance with the law.

"This decision is an important step toward restoring the fair and balanced process that Congress enacted to resolve disputes between health insurers and physicians over appropriate out-of-network payment rates. The decision will promote patient access to quality care when they need it most and will guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices."

TMA Welcomes U.S. District Court Decision to Grant Its Summary Judgment Motion

www.texmed.org

 

[Arch Guillotti]

So what does that mean in the grand scheme of things? Not clear what a ruling in a state court does as ot relates to federal law.

 

[lane]

So what does that mean in the grand scheme of things? Not clear what a ruling in a state court does as ot relates to federal law.

It’s a federal court, so it should apply everywhere

 

[Endee]

So what does that mean in the grand scheme of things? Not clear what a ruling in a state court does as ot relates to federal law.

That’s a federal district court ruling that applies nationwide.

However, a number of things could happen. HHS will appeal. The whole law could get stayed. Or it could proceed without the QPA guidance.

 

[teacher2md]

Potentially great news regading the NSA act— in light of the federal case in Texas, CMS appears to be re-working their implementation of the QPA;

 

[kidthor]

Whatever the outcome I'm thankful the ASA is fighting for us on these things. They're really stepping up their game lately. I heard the current ASA president give a talk recently and he very much know what was going on medical/politically and was advocating for us well.

 

[anbuitachi]

Whatever the outcome I'm thankful the ASA is fighting for us on these things. They're really stepping up their game lately. I heard the current ASA president give a talk recently and he very much know what was going on medical/politically and was advocating for us well.

yes problem is hes gone in a year. the constant switching of presidents is frustrating since a lot of the work is 'long ' term

 

[Mman]

i dont understand why anesthesiology insurance pay has to be so complicated. with time units and all.
why cant anesthesiologist billing be exactly the same as surgeons if the surgery requires anesthesia?

eg; if lap appy surgery bills for 10000 for surgeon, then bill 10000 for anesthesiologist.

it was originally created (I believe) as a boost for academic practices that were slower and less efficient. If you are in academics, it doesn't seem fair to get paid the same amount for an anesthetic for a 4 hour lap chole as a private group gets paid for a 30 minute lap chole.

 

[Endee]

yes problem is hes gone in a year. the constant switching of presidents is frustrating since a lot of the work is 'long ' term

The vast majority of this work happens at the staff level not the physician/officer level.

 

[anbuitachi]

it was originally created (I believe) as a boost for academic practices that were slower and less efficient. If you are in academics, it doesn't seem fair to get paid the same amount for an anesthetic for a 4 hour lap chole as a private group gets paid for a 30 minute lap chole.

but isnt that the same for the surgeon

 

[Mman]

but isnt that the same for the surgeon

surgeons have control over how long the surgery takes as opposed to anesthesia that just passively watches the cost go down the toilet for no added revenue if you billed like the surgeon

 

[anbuitachi]

surgeons have control over how long the surgery takes as opposed to anesthesia that just passively watches the cost go down the toilet for no added revenue if you billed like the surgeon

sure but the average surgeon still makes way more than anesthesiologist if subspecialties included. they arent even in OR that much since they have clinic

 

[Mman]

sure but the average surgeon still makes way more than anesthesiologist if subspecialties included. they arent even in OR that much since they have clinic

that doesn't really have anything to do with why surgeons get paid a flat fee for a given procedure vs why anesthesia has base units for the procedure and time units depending on how long it takes.

 

[kidthor]

With bundled payments now we will be paid a flat fee. But I guarantee you it’ll be a fraction of the surgeon fee, and theirs will be a fraction of the facility fee.

 

[deleted941485]

With bundled payments now we will be paid a flat fee. But I guarantee you it’ll be a fraction of the surgeon fee, and theirs will be a fraction of the facility fee.

Is this a regular occurrence now?

 

[Arch Guillotti]

Is this a regular occurrence now?

Not too much.

 

[nimbus]

that doesn't really have anything to do with why surgeons get paid a flat fee for a given procedure vs why anesthesia has base units for the procedure and time units depending on how long it takes.

And their flat fee includes 90 days of postop care. They are really incentivized to minimize complications. At least we get paid each time the patient is brought back to the OR. Exploration for postop chest hemorrhage?…..sure….15 base units.

 

[kidthor]

Is this a regular occurrence now?

Not common, yet. But the payors want to do it more. It's most common with ortho joints for now.

 

[anbuitachi]

And their flat fee includes 90 days of postop care. They are really incentivized to minimize complications. At least we get paid each time the patient is brought back to the OR. Exploration for postop chest hemorrhage?…..sure….15 base units.

does our flat fee include outcomes..? or do we drop them off in pacu and its donezos

 

[nimbus]

does our flat fee include outcomes..? or do we drop them off in pacu and its donezos

No. We get paid every time they come back.

 

[Arantius]

Resurrecting this thread in light of recent events. Now there are 90,000 claims in IDR and I read that CMS initially expected 2200. They just have no clue how f’ed this process is. Is this a plan to get us all to Medicare for all?

 

[IMGASMD]

Resurrecting this thread in light of recent events. Now there are 90,000 claims in IDR and I read that CMS initially expected 2200. They just have no clue how f’ed this process is. Is this a plan to get us all to Medicare for all?

Only 40x more than they thought? Some of these group will never any money from the process.

 

[anbuitachi]

are there any other specialties that bills like us? by time?

 

[chessknt]

are there any other specialties that bills like us? by time?

Nope

 

[Liquidice07]

Came here to find some discussions around this. Been starting to notice this kind of market dynamic, too. Sites like turquoise.health or mdsave.com or expectedhealthcare.com seem to be trying to these types of transparent, pay upfront sites. Wonder if they'll take.

 

[HemeOncHopeful19]

Resurrecting this thread in light of recent events. Now there are 90,000 claims in IDR and I read that CMS initially expected 2200. They just have no clue how f’ed this process is. Is this a plan to get us all to Medicare for all?

Someday it will come out that some higher up people left CMS to form a mediation company