News & Updates

Becker's Source Article | Comments Courtesy of Matt Zavadsky

This might be something to keep in our quiver as discussions continue on surprise payments.

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Former UnitedHealth exec says company would only pay surprise bills after complaints

November 12th, 2021

Nick Moran

The former head of UnitedHealthcare's Shared Savings Program alleged during testimony that the insurer was willing to pay for its members' surprise medical bills, but only if they filed a complaint to the company.

 

The testimony is part of the ongoing legal battles between UnitedHealthcare and TeamHealth. John Haben, the former UnitedHealthcare executive, has been testifying in Nevada over a TeamHealth lawsuit that alleges the insurer's Shared Savings Program resulted in millions of dollars in clinician underpayments.

 

During his testimony, Mr. Haben told prosecutors that UnitedHealthcare's explanation of benefits told members they could raise questions about reimbursement but did not explicitly say UnitedHealthcare would pay for surprise bills, according to a Nov. 11 news release.

 

He also claimed that UnitedHealthcare undercut providers through the program, paying them as little as 20 percent of billed charges.

 

A UnitedHealthcare spokesperson told Becker's that TeamHealth's lawsuit doesn't hold any weight but that it does serve as a distraction against TeamHealth's decision to leave the insurer's provider network.

 

"This lawsuit is meritless and is just another example of TeamHealth’s efforts to distract from the real reason it no longer participates in our network, which is their unreasonable demands that they be paid double or even triple the median rate we pay other physicians providing the same services," the UnitedHealthcare spokesperson told Becker's. "We are committed to addressing these unreasonable and anticompetitive rates that many private equity-backed physician staffing companies charge for services, which drive up the cost of care for our customers, members and the health care system."

 

TeamHealth contested the claims in UnitedHealthcare's statement, pointing to one instance mentioned in court where the insurer allegedly reimbursed $254 for a gunshot wound treatment billed at $1,428, despite Mr. Haben calling the full price tag "worth" the charge.

 

“UnitedHealthcare's goal has been to reap larger profits at the expense of frontline healthcare providers and their patients," the TeamHealth spokesperson told Becker's. "In the Nevada courtroom, TeamHealth is proving that United orchestrated a scheme to artificially and fraudulently reduce payments to physicians."

 

We’d like to thank the 247 respondents to the AIMHI COVID Vaccine Flash Poll.  Results from the poll are summarized here.

Our goals for the Flash Poll are to share the current state of COVID vaccine implementation across a broad section of the EMS profession, and disseminate the experience of agencies related to this important topic.

We’d also like to thank the 85 EMS agency leaders from all provider types who indicated they are willing to share their policies and procedures!  A list of these agencies, including their provide type, can be found here.

Modern Healthcare source article

ALEX KACIK

October 04, 2021

Air ambulance utilization and charges have been steadily increasing over the past several years, according to a new study.

The average in-network negotiated rate for emergency transport by airplane—excluding mileage charges—rose 76.4%, from $8,855 in 2017 to $15,624 in 2020, according to a FAIR Health analysis of around 35 billion healthcare claims. But most air ambulance rides are out of network, leaving consumers to pay for most of the charges.

The average charge associated with airplane ambulances rose 27.6%, from $19,210 in 2017 to $24,507 in 2020. The average Medicare reimbursement rose 4.7% to $3,216 over that span, the same rate increase as emergency helicopter rides.

The average charge associated with ambulance by helicopter rose 22.2%, from $24,924 in 2017 to $30,446 in 2020.

...

The Biden administration published an interim surprise billing rule last week, which states that providers and payers can turn to an independent dispute resolution process if an out-of-network provider and payer can't come to an agreement over payment during a 30-day "open negotiation."

Read full article►

Modern Healthcare Source Article

TARA BANNOW & JESSIE HELLMANN  

October 01, 2021

Providers are crying foul about a regulation from the Biden administration that lays out the process they can use to settle out-of-network billing disputes with payers.

The rule, released Thursday by the Centers for Medicare and Medicaid Services, is the next step in its implementation of the surprise billing ban passed last year by Congress.

Payers praised the regulation as the "right approach," while providers swiftly denounced it as a "miscue" arbitrarily favoring insurers. At issue is the part of the regulation that lays out the independent dispute resolution process used when there is a disagreement between providers and payers over the fair price for an out-of-network service.

In the IDR process, both the insurer and provider tell an arbiter what they think the appropriate rate for an out-of-network service is. CMS directs the arbiter to presume the "qualifying payment amount," which is usually an insurer's median contracted rate for the same service in a geographic area, is the "appropriate" rate and pick the offer closest to that.

In the providers' minds, that gives insurers too much leverage.

"It goes way beyond protecting patients. It protects insurance companies and gives primary credence to their point of view and data," said Chip Kahn, CEO of Federation of American Hospitals. FHA is a trade group that represents for-profit hospitals.

 Continue reading►

This a VERY WELL-DONE, research and evidence-based commentary on the cause, effect, and recommended SOLUTIONS to ED overcrowding.

It’s a bit long, but well worth the read!  A PDF of the commentary is attached.

All facets of the healthcare system, including EMS, need to work together to appropriately navigate patients, especially those who access healthcare through ‘911’, through effective integration.

Tip of the hat to Rob Lawrence for sharing this article!

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Emergency Department Crowding: The Canary in the Health Care System

The solution for this serious threat to ED staff and harm to patients cannot come from a single department, but through engagement of and ongoing commitment by leaders throughout the hospital and, more broadly, by those in the payer and regulatory segments of the health care system as well.

September 28, 2021

By: Gabor D. Kelen, MD, Richard Wolfe, MD, Gail D’Onofrio, MD, MS, Angela M. Mills, MD, Deborah Diercks, MD, Susan A. Stern, MD, Michael C. Wadman, MD & Peter E. Sokolove, MD

https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217

The impact of ED crowding on morbidity, mortality, medical error, staff burnout, and excessive cost is well documented but remains largely underappreciated.

Among the most notable content in the commentary:

Emergency department crowding is a sentinel indicator of health system functioning. While often dismissed as mere inconvenience for patients, impact of ED crowding on avoidable patient morbidity and mortality is well documented but remains largely underappreciated. The physical and moral harm experienced by ED staff is also substantial. Often seen as a local ED problem, the cause of ED crowding is misaligned health care economics that pressures hospitals to maintain inefficient high inpatient census levels, often preferencing high-margin patients. The resultant back-up of admissions in the ED concentrates patient safety risks there. Few efforts (even well-meaning ones) address the economically driven root causes of ED crowding, i.e., the need to achieve minimal financial hospital margins. The key to a sustainable solution is to realign health care financing to allow hospitals to keep inpatient capacity below a critical threshold of 90%; beyond that, hospital throughput dynamics will inevitably lead to ED crowding.

Even prior to the Covid-19 pandemic, greater than 90% of U.S. EDs found themselves stressed beyond the breaking point at least some of the time. Many remain overwhelmed daily.

The authors provide detailed commentary on:

• Causes of Crowding and Why ED Crowding Persists
• • Health System Incentive Structure
  • Insufficient Health Care Capacity
  • Failure of Regulatory Agencies, Payers, and Legislative Bodies
  • Misunderstanding of the Issue

• Solutions:
• • ED Input Solutions
  • • Distinct from individual hospitals placing themselves on ambulance diversion is a new voluntary 5-year payment model by the Centers for Medicare & Medicaid Services (CMS): Emergency Triage, Treat, and Transport ET3 for Medicare fee-for-service beneficiaries calling 911. In this model, CMS will pay participants to transport to an alternative destination partner, including primary care offices, UCCs, or even community mental health centers. In and of itself, ideally, only low-acuity patients would be transported to other settings and, thus, no significant impact on ED crowding from boarding is expected. Indeed, we have apprehension about Medicare patients being sent by ambulance to nonemergency care settings given the occult medical vulnerabilities of such patients and the high rates of needed hospital admission associated with ambulance transports.

• ED Throughput Solutions
• • Hospital Solutions to Relieve Access Block (Output)

The authors recommend five essential elements to take on overcrowding in the ED:

1. ED crowding must be acknowledged as the serious problem to patient safety that it is — and not the “inconvenience” it is perceived to be.
2. Most important, there are no known examples of successful amelioration of ED crowding in any institution without significant visible buy-in and action directed from senior-most institutional leadership. This commitment must be continuously evident with incentives of management at all levels throughout the institution and aligned to resolve this most important patient safety concern.
3. Many institutions operate on razor-thin margins. Health care financing must realign reimbursement from current practices that outright promotes ED boarding.
4. Regulators such as TJC and CMS must clearly address the impact of crowding on patient safety, its potentiation of violence, and its implications for staff well-being; likewise, the Accreditation Council for Graduate Medical Education should consider the impact of crowding on training and trainee well-being within their credentialling criteria of institutions. The regulations should include clear metrics and associated penalties/consequences.
5. Crowding is predictive and, accordingly, enforceable preemptive surge plans must be generated and actuated. When crowding does occur, it must be considered in the same light as a disaster with the same deliberate moral response.

Rural areas suffer from ambulance shortage

CBS News Saturday Morning

September 25, 2021

Another compelling news story about the rural ambulance service challenges.

While this CBS Saturday Morning news story, which aired September 25th, highlights the report from the Rural Health Policy Institute, similar challenges exist for many ambulance providers in urban and suburban communities as well.

• Crisis level staffing shortages

• Inadequate reimbursement

• Lack of designation as an ‘Essential Service’

In the news story, Alan Morgan, the director of the National Rural Health Association, states that the failing rural ambulance system may be contributing to the falling life expectancy in rural communities.

https://www.cbs.com/shows/cbs-saturday-morning/video/otcflmmL9GJu2seC9Ea0YeU45X8qGXyF/report-rural-areas-wait-longer-for-ambulances/  

Here’s a link to the RHPI Report.

CBS Saturday Morning Source | Comments by Matt Zavadsky

The latest census report finds that 60 million Americans live in rural areas. The Centers for Disease Control and Prevention reports that they tend to be older, sicker and poorer than the average American. According to a study by the Rural Policy Institute, there are not enough ambulances to help in an emergency. CBS News transportation correspondent Errol Barnett has the story. Air Date: Sep 25, 2021

CBS News Source Article | Comments by Matt Zavadsky

Our healthcare system is buckling! 

Scenarios like this should NOT be happening.  Please watch the video in the news link.  The frustration expressed by a caring physician who is simply trying to get the right care for his critical, non-COVID patient is compelling.  This scenario is playing out all over the country. 

Non-COVID patients are dying because the hospitals are packed with COVID patients.  98.3% of people hospitalized with a COVID-19 diagnosis between May and July 2021 were unvaccinated (https://www.healthsystemtracker.org/brief/unvaccinated-covid-patients-cost-the-u-s-health-system-billions-of-dollars/).

EMS response volumes and ER delays are also impacting local EMS systems – delaying care to critical 911 callers due to stretched EMS resources.

Our healthcare system is buckling!! 

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Patients forced to wait thousands of minutes in rural Texas ER: "We've never seen this. Ever."

CBS-mornings

SEPTEMBER 7, 2021

https://www.cbsnews.com/news/texas-covid-patients-overfill-hospitals/

WRDW Source | Comments by Matt Zavadsky

The latest news report about an issue facing many EMS systems and communities across the country.

AIMHI is hosting an international webinar with EMS, hospital and EMTALA experts on Tuesday, September 7^th beginning at 1p Central Time.

Click here to learn more and register for the event.

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COVID surge overruns local hospitals, slowing ambulance responses

By Kennedi Harris

Aug. 30, 2021

https://www.wrdw.com/2021/08/31/recent-covid-surge-makes-augusta-ambulance-response-times-even-longer/

AUGUSTA, Ga. (WRDW/WAGT) - The number of COVID patients continue to grow at all of our local hospitals. We’re told inside some hospitals, hallways are lined with patients waiting in chairs.

At Augusta University Health, doctors say hallways are lined with beds. Outside the doors you may see lines of ambulances waiting to get in.

In the past, Gold Cross EMS, Richmond County’s primary ambulance service provider, has reported long wait times outside of hospitals. That’s holding ambulance units up and leaving fewer units available on the street. Now Gold Cross says the COVID surge is making those wait times even longer.

On Monday, under the emergency awning at University, there were lines of ambulances. AU Health and Doctors Hospital had a very similar sight. It’s an issue that COVID is making worse but there’s a way you can help.

Before you make the call be prepared because you might have to wait.

“We’re seeing wait times, that in some cases may seem astronomical. But this is a direct reflection of where we are based on COVID,” said Michael Myers, Gold Cross EMS director of business development.

An ambulance can’t just drop a patient off and go. They must complete a transfer of care to the hospital. But because ERs are full, EMS crews are sitting outside with patients waiting for an ER room to open up. Depending on the timing the wait can be anywhere from 30 minutes to as long as six hours.

“We can have a crew that can get to a hospital but, but they may have to wait there. In some cases, hours with a patient, because there’s no room inside,” he said.

In a real example from over the weekend, Gold Cross picked up a patient at 9:58 a.m. and arrived at a local hospital at 10:34 a.m. but couldn’t leave until a room was available at 6:43 p.m.

“We’ve always had wait times. COVID has extended the wait times” he said.

Myers encourages you to think before you call so you’re not taking ambulances away from possibly more critical needs.

“Because we are in these times of COVID, we have to make sure that we are using our resources in the most appropriate or efficient way as possible,” he said. “My thought processes - if you can drive yourself to an emergency room, you probably don’t need to call 911.”

Myers says they’ve even seen people calling an ambulance to get tested for COVID. Don’t do that he says, get tested outside of the hospital if possible. If you do need to be taken to the ER by ambulance have patience. You won’t be seen any quicker just because you come by ambulance. Hospitals are caring for the most critical needs first.

Congratulations to the 2021 AIMHI Award Winners!  

2021 AIMHI Excellence in EMS Integration Awards

• Texas Health Resources
• Exodus Recovery
• Washoe County, Nevada

 

2021 AIMHI Leadership in Integrated Healthcare Awards

•  Janice Knebl, DO, MBA, FACP, MACOI

 

2021 AIMHI Excellence in Education

• Pro EMS Refresh

 

2021 AIMHI Excellence in Value Demonstration or Research Awards

• Niagara EMS
• University of Southern California & Los Angeles Fire Department

 

2021 AIMHI Excellence in EMS Advocacy Awards (NEW CATEGORY!)

• Senator Catherine Cortez Masto
• Indiana State Senator Karen Tallian 

 

2021 AIMHI Lifetime Achievement Awards

• Josef Penner
• Jon Swanson