Author Archive for Madison Williams

EDPMA survey reports that emergency medicine physician groups experience a 39% reduction in out-of-network reimbursement since the implementation of the No Surprises Act.

The Emergency Department Practice Management Association released new data analyzing the impact and compliance issues of the No Surprises Act since its implementation in January 2022. Key findings include a 39% reduction in out-of-network reimbursement which suggests a significant decrease in commercial health plan reimbursement despite consistent demands on high-quality care and exacerbates existing workforce shortages and workplace strain. These dramatic declines in commercial reimbursement are occurring against the backdrop of Medicare fee schedule cuts and the lack of an inflation adjustment to the Medicare physician fee schedule. Read the press release and the study here.

EDPMA Files An Amicus Brief To Support The TMA III Appeal

The TMA III appeal concerns the Departments’ July 2021 Interim Final Rule regarding calculation of Qualifying Payment Amounts (“QPAs”), as well as payors’ disclosure obligations regarding their QPA calculations. The district court decision addressed two aspects of the July Rule.

First, the district court vacated certain provisions of the July Rule dealing with the actual calculation of the QPA: (1) the inclusion of “ghost rates” in QPAs; (2) the exclusion from the QPA of risk-sharing, bonus, and other incentive-based or retrospective payments; (3) the inclusion of out-of-specialty rates; and (4) the inclusion of other plan sponsors’ rates.  On appeal, the Departments did not challenge the district court’s vacatur of the third and fourth provisions, other than to appeal the district court’s decision to order “universal vacatur” applying to parties beyond the TMA III case. That leaves ghost rates and incentive payments at issue on this appeal.

Further, EDPMA and its members continue to advocate for HHS’ enforcement and guidance on these two vacated elements to ensure go-forward QPA calculations adhere to single specialty requirements while prohibiting TPAs from using rates from other self-funded plans they administer.  In fact, questions to ensure compliance with these elements were recently posed by U.S. House Ways & Means committee members to Secretary Becerra at a recent budget hearing.

Second, the district court disagreed with TMA and did not vacate the July Rule’s disclosure and transparency provisions for insurers regarding their calculation of the QPA. TMA is cross-appealing that portion of the district court’s ruling.

EDPMA’s amicus brief supports TMA’s position on both the Departments’ appeal and on TMA’s cross-appeal.

First, EDPMA argues that the July Rule’s provisions regarding calculation of the QPA are contrary to the unambiguous language and legislative intent of the No Surprises Act (“NSA”). The intent of the NSA was not only to protect patients from “surprise” medical bills, but also to ensure fair and reasonable reimbursement rates to out-of-network physicians. The challenged provisions of the July Rule regarding calculation of QPAs skew the QPA unfairly downward and result in significantly below-market rates for physicians.

Second, EDPMA argues that the district court erroneously declined to vacate the July Rule’s insurer disclosure obligations. The July Rule fails to require insurers to provide basic, material information to physicians that would enable them to evaluate the QPA and make informed decisions about the offers they should submit in the IDR process, or even whether to invoke IDR at all.

Third, in addition to the legal arguments noted above, EDPMA informs the Court about the real-world consequences of the Departments’ implementation of the NSA. In so doing, EDPMA relies on a variety of reports and studies of the NSA and the IDR process, including some truly outstanding work done by EDPMA.

For example, an EDPMA study, among others, show that out-of-network reimbursements to emergency physicians have actually decreased since implementation of the NSA 92% of the time, with an average decrease in payment of more than 32% for each emergency room visit.  Moreover, the significantly below-market QPAs as calculated by insurers have resulted in enormous backlogs in the IDR process, resulting in further delays in payments to physicians. EDPMA also describes how the July Rule’s weak disclosure and transparency obligations of insurers regarding their calculation of the QPA have left physicians in the dark about the process.

The Departments have done little to enforce those disclosure obligations or to audit the IDR process. EDPMA also describes how the Departments’ implementation of the NSA has resulted in a dramatic contraction of provider networks―directly contrary to the intent of Congress. Insurers have been emboldened by the Departments’ regulations and have terminated longstanding network agreements or forced physicians to accept substantial discounts from their contracted rates. Thus, contrary to the Departments’ assertions that it is the “business model” of emergency medicine groups to “remain out of network,” it is insurers that have been forcing physicians out of network. The brief also notes that while physicians generally have been adversely affected by the Departments’ rules, emergency physicians have been particularly affected by them, especially given their obligations under EMTALA to treat all emergency room patients, regardless of their insurance status or ability to pay.

Perhaps most important, EDPMA’s brief is not limited to describing the harm to physicians from inadequate reimbursement.  The brief also demonstrates that the Departments’ rules adversely affect patients and have exacerbated the existing crisis in the emergency medicine delivery system. The burden of shouldering uncompensated and undercompensated care has resulted in the closing of emergency rooms or the downgrading of services, thereby potentially crippling the nation’s healthcare safety net, particularly in rural and underserved areas. The Departments’ implementation of the NSA will serve only to worsen this situation. Read Here.

EDPMA at ACEP24

EDPMA Reception at ACEP24

Monday, September 30, 2024
6p – 8p PST

Rhythm & Riffs
Mandalay Bay Resort and Casino – Las Vegas
Casino Floor

RSVP

Sponsored by:

Walking Directions From The Front Desk
From the front desk, begin walking through the casino floor past the Noodle Shop. Rhythm & Riffs will be straight ahead.

The Power of State Advocacy – Presented by the EDPMA State Regulatory and Insurance Committee (SRIC) 

Are You Ready To Be A Changemaker In Your State? 

Attend The Power of State Advocacy members-only free webinar to learn how state advocacy can drive policy change.  

Members will gain insights into effective communication strategies, building strong relationships with state officials, and understanding the immediate impact policies can have at the state level.  

Presented by our State Regulatory and Insurance Committee, this program will equip you with the knowledge and skills needed to become effective state advocates. 

Thursday, February 29
2pm EST 

Learning Objectives: 

  1. Understand the importance of effective communication in state advocacy: 
    1. Explore different communication channels such as writing persuasive letters, making phone calls, and utilizing social media platforms. 
    2. Learn how to tailor messaging to resonate with state policymakers and constituents.
    3. Analyze successful communication strategies used in previous state advocacy campaigns.
  2. Develop relationship-building skills to enhance state advocacy efforts:
    1. Explore techniques for cultivating relationships with state officials, elected representatives, and key stakeholders.
    2. Understand the benefits of building coalitions and collaborating with other advocacy organizations.
    3. Gain insights into the art of fostering long-term relationships for sustained policy influence.
  3. Recognize the immediate impact of policies at the state level:
    1. Explore case studies that demonstrate how state policies can swiftly affect communities and individuals.
    2. Learn how state-level policy changes can set precedents and influence broader national policies. 

After this 60-minute webinar, members will be equipped with the knowledge, skills, and resources to engage in effective state advocacy. You will understand the importance of communication, relationship-building, and the immediate impacts of policies at the state level, ultimately empowering you to make a difference in their communities through advocacy efforts.

Learn More!

2024 EDPMA Solutions Summit

Join us in Seattle for Solutions Summit 2024, a one-of-a-kind education and networking conference. Plus 5 meals and 2 receptions.

The 2024 Solutions Summit is the most comprehensive conference on the business of emergency medicine covering topics you care about including the No Surprises Act, reimbursement and regulatory policy, independent dispute resolution, revenue cycle management, and much more.

Why Attend Solutions Summit?

Attending the 2024 Solutions Summit has never been more essential. Last year at the 2023 Summit, we saw our largest turnout ever because attendees know that at this conference they can experience:

  • Exceptional Faculty: Gain insights from thought leaders and disrupters in the business of emergency medicine. 
  • Networking Opportunities: Connect with like-minded professionals and expand your network. 
  • Cutting-edge Sessions to enhance your skills and knowledge. 
  • Innovative Exhibitors: Explore the latest products and services from top companies in the field. 
  • Exclusive Access: Be among the first to access best practices and industry trends. 

Interested in sponsorship or exhibiting? Contact Joanne at joanne.tanner@edpma.org.

NOTE: Registered attendees will receive a link to the official Solutions Summit room block in their confirmation email.  Since we make every effort to secure the lowest rate, we ask that you only make your hotel reservations through our special link. We strongly urge attendees NOT to use a third-party vendor to make their hotel reservations. 

2024 Solutions Summit Agenda At A Glance

April 26-30, 2024
Seattle, WA

Friday, April 26 – Pre-Conference Reception (tentative)
Saturday, April 27 – Committee Programming, Exhibitor Set-up & Welcome Reception
Sunday, April 28 – Summit Day 1
Monday, April 29 – Summit Day 2, Exhibitor Tear Down & Closing Reception
Tuesday, April 30 – Summit programming concludes at 12p; Tuesday features dynamic hard-hitting topics, so stay for the entire conference!

Learn More!

2024 RCM Updates: Moving Regulations to Practice Virtual Workshop

EDPMA’s 2024 RCM Update: Moving Beyond Regulation to Practice virtual workshop will raise your expertise so you are ready for 2024 reimbursement changes and challenges.  

Through rapid fire and deep dive interactive sessions, you will learn optimal reimbursement practices to strengthen your organization and your clients’ bottom line.  

Workshop Focuses On Updates and Best Practices In:  

  • Addressing Bad Payer Behavior 
  • Coding (plus hands-on coding exercises) 
  • Documentation 
  • Medicare Physician Fee Schedule 
  • MIPS 
  • Split/Shared 
  • Telehealth

Workshop Agenda and Faculty:

  • Medicare by the Numbers: The Basic Tenets of Physician Reimbursement  (15 minutes)

Andrea Brault, MD, MMM, FACEP – President and CEO, Brault Practice Solutions

  • MIPS and MVPs: The Evolving Landscape of Medicare Reimbursement  (45 minutes)

Andrea Brault, MD, MMM, FACEP – President and CEO, Brault Practice Solutions

  • Understanding Payer Behavior: A Panel Discussion  (45 minutes)

Patrick Velliky – Vice President Government Affairs, Envision Health

Eric Swartz – Deputy General Counsel, ApolloMD

Moderator: Casey Crane, MBA, RN, BSN – Senior Vice President of Operations, Core Clinical Partners

  • Telehealth Reimbursement: What’s In, What’s Out for 2024  (30 minutes)

Juli Forde Smith – Director of Strategic Partnerships, Zoll Data Systems

  • Case Studies in Coding (45 minutes)

Jacquie Bratcher, CPC, CEDC – Senior Director of Coding, R1 RCM

Bart Robinson – Director of Coding Quality, Core Clinical Partners

Theresa Schwegmann, RHIA, CPC – Vice President of Coding Services, SCP Health

Moderator: Jason Adler, MD, FACEP, FAAEM – Vice President of Coding, LogixHealth

 

*There is a 10 minutes break for attendees during this workshop

Sessions will be presented at the 300 and 400 level. 

Who Should Attend?  

Leaders in: 

  • Coding 
  • Revenue Cycle Management 
  • Compliance and Audits 
  • Documentation

Thursday, January 18
1p – 4p EST 

Learn More

WebinarPLUS: Unpacking the Final Rule – MIPS + Medicare PFS

This webinar is designed to provide EDPMA members like you with insight into the latest news on Medicare reimbursement, including detailed updates on MIPS, the new Emergency Medicine MVP, and other topics covered under the Final Rule. Don’t miss this opportunity to learn from the experts and ask questions on how to prepare for the coming year.

November 30, 2023 – 1:00pm ET

This webinar is sponsored by Brault. Click here to register.

Webinar+ Four Key Pillars to Denial Prevention Sponsored by Waystar

Join us for an informative and engaging webinar that delves into the critical aspects of denial prevention in the modern world. Denial prevention is an essential component of safeguarding your organization’s assets, reputation, and security. In this webinar, we will explore the four key pillars that form the foundation of effective denial prevention strategies.

November 1, 2023 – 1:00pm ET

Cost: Free to EDPMA Members.

Location: Hosted on Zoom (Zoom link received upon registration)

Faculty:  Christine Fontaine, Solution Strategist, Waystar

Click here to register.

Statement on New Federal Guidance on the No Surprises Act

On Friday October 6th, the Centers for Medicare & Medicaid Services (CMS) announced new guidance in response to the August ruling in Texas Medical Association v. United States Department of Health and Human Services (“TMA III”) that vacated several provisions of the existing No Surprises Act (NSA) regulations. Our organizations are strongly opposed to this newest guidance, which further broadens the already significant discretion health plans had on how they may calculate qualifying payment amounts (QPAs) under the NSA’s original implementation.  In the announcement, the Departments state that no additional guidance is expected to be provided to health plans about how to calculate the QPA, and instead, simply leaves insurers the discretion to calculate QPAs using their own “good faith” interpretation of the TMA III ruling and remaining regulations. Read more.

EDPMA and Others Urge HHS to Reopen The Federal IDR Portal

As the No Surprises Act’s Independent Dispute Resolution (IDR) portal surpasses the 8-week mark since its halt of full operations for the filing of new IDRs, the American College of Emergency Physicians, American College of Radiology, American Society for Anesthesiology, the Emergency Department Practice Management Association, and Radiology Business Management Association together urged the U.S. Department of Health and Human Services to reopen the national portal. Read More.