US BEACON

Our very own @kcarle_kim discusses payment integrity in medical claims with @RelentlesHealth you do not want to miss! cc-lnk.com/EP480 #HealthcareReform #healthcarecrisis #claimsintegrity

That is absolutely our company. Typically this big BUCAHS will not allow us in, but the TPAs (and that's very few) allow us to clean the claims and pay the provider what is owed and the patient to pay ONLY what they owe. My mission started with a purpose, when you have a family member, which in my case was my husband, diagnosed with stage 4 cancer and you become part of the system, you become passionate about fairness in healthcare. Since then, my eyes have been opened up to the fraud.

@us_beacon @BrokenMoats @mcuban This you? Working for the enemy?

The greatest problem in healthcare ? Hospitals, even market dominant hospitals, won’t walk away from the big ins companies that underpay, late pay, clawback, deny claims, waste their time in denial appeals, and require them to pay up to 8 pct of revenue to RCM consultants so they think they are getting what they are owed. Here is the crazy part. The ins companies ARE NOT THE ONES ACTUALLY PAYING THEM on commercial plans. Employers are. 60 pct of employees get their insurance from their self insured employers. The ins carrier is just a middleman that pretends to add value. All the clinical “value” they add, the hospital could do better, for both medical and pharmacy. Most hospitals have no idea whether they make or lose money with their big ins contracts. They are just afraid to lose patient flow. But. They actually know which companies their patients are coming from. They actually know or can find out, how much more the employers are paying the ins company, than what the ins company pays them (the spread, just like in pharmacy ) And to make it worse, those ins companies negotiate their rates as a discount from the “charge master “, which is like WAC in pharmacy. Just a made up list price. Because the hospitals are afraid or too uninformed to walk away from these deals, the hospitals use the inflated charge master prices as the basis to charge uninsured , or out of network , or insured but not covered for their care, at charge master rates. Which of course the patients can’t afford. And it crushes their finances or they go without care I’ll summarize. Employers , and their members , are paying far more than they should to companies they don’t like working with , that effectively rip off both the employer and hospital , and they could eliminate the middlemen if they went directly to to the employer. It’s so simple. Sell your services to the employers that use your services at a price that is less than what nine companies charge for your services and you will make MORE money and employers will save a ton And if they did this, they could dump the chargemaster and reduce the price they bill patients when they are at their most vulnerable But they don’t want to change. And don’t get me started on how much hospitals over pay for drugs and devices because of the GPO deals they do. It’s just stupid. Which in turn leads to the hospital being a bad actor with 340b , facilities fees and afraid of their doctors who demand they pay more for things like glue and implants so they can get vacations. If you are a politician and reading this. Now you know why this is so fucked up and it’s not about capping rates. The insurance companies are smarter than you. They will just move the money to other places. It’s not about giving money to patients. You can’t shop for care from hospitals that are too gutless to walk away from the ins companies that distort all of healthcare economics Go to your local hospitals , particularly those at risk of closing and ask for their profitability by carrier. Fully burdened. Ask how much they spend on RCM and consultants. In many cases they could survive if they ran like a real business and hired execs that could do the work rather than just manage consultants. They could work out contracts in their communities rather than with ins companies and benefit everyone. The middlemen are not needed. Get rid of them

@GoodPoint123 @TheChrisWright @mcuban Insurance companies and fraud have the same meaning...as long as it enhances their revenue.

@TheChrisWright @us_beacon @mcuban thanks. and why would insurance companies accept that ? seems like scammy practice if not outright fraud

Guys. This means the absolute WORLD to us!!! Despite not seeing any patients our first day (at all, blessing in disguise we still have a lot to do) we have been getting flowers from you and it means everything. ❤️🥲 @kaufcare day one ✅

Update!

@AmySandSand @BrokenMoats @mcuban Let’s agree to disagree. I don’t have a strong need to defend, those who do usually have a reason...

@us_beacon @BrokenMoats @mcuban They aren’t errors. They deny a certain percentage across the board. The only business where services are given and go unpaid.

@kp07110 @mcuban If it were going to the Dr's representing the care, maybe a different story...unfortunately it is not. Regardless, if you get a bill that states you owe $5,000 do you just pay it without question?

@us_beacon @mcuban Manipulate, or fairly represent the care they are providing?

Yes, that is proudly our company. We are 100% independently owned by my husband and me, no debt, no investors, no outside influence. Many of the BUCAHs won’t work with us, we’re not a “preferred vendor,” and that’s by design. But the independent TPAs who are willing to do what’s right for the patient call us regularly. In all my years, I’ve never seen a completely clean bill.

You don't know us or me and what we stand for. I don't need to explain to you. I’m focused on facts and accountability, not sarcasm. That’s how things actually get fixed. Problems aren’t solved when the conversation is one-sided and dismissive, it’s unproductive and unprofessional.

@AmySandSand @BrokenMoats @mcuban "Insurance companies mad because they can’t fight it well. 😂🤣😂🤣😂🤣😂" That’s a pretty dismissive take. There are real issues here that deserve serious discussion, not sarcasm.

@BrokenMoats @us_beacon @mcuban Hi. Actual Coder here. The AI READS the medical record and has access to the insurance contract and their rules for payment. Together-they throw the most appropriate codes to create a payable DRG. FAIR Insurance companies mad because they can’t fight it well. 😂🤣😂🤣😂🤣😂

Apparently, this is a newer version. We were given the information from the meetings, the hospital and company collaborated to develop and market it to other hospitals. While similar concepts may have existed before, this particular system is new and designed to drive revenue, it was clear in the internal discussions.

@us_beacon @mcuban You’re quite a few years late! AI has assisted in RCM for at least 12+ years and is implemented in the majority of large health systems

@BrokenMoats @mcuban Of course it is, but they will state it was a "mistake", it happens on every single claim...always get your itemized bill!

The codes are not set per procedure, codes are added into codes when you actually obtain the itemized bill. A delivery of a baby was $60K with a rev code on a UB04, when we obtained the itemized statement, the CPT codes were broken out-$28,000 was the dad standing in the delivery room...

@noahkaufmanmd @BrokenMoats @mcuban Yes it is. It's sickening.

@BrokenMoats @us_beacon @mcuban Insurance fraud is basically the status quo. Like for all hospitals and all coding. It’s disgusting.

@AmySandSand @BrokenMoats @mcuban The company was brought in to drive revenue- I know this for a fact. I’m highly experienced in this area and also a coder.

@mcuban One of the nice, big, supposedly "Christian" nonprofits.

Which hospital?

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Is Mr Mulligan still consulting for the PBM industry? @mcuban

"[PBMs] are the Darth Vader of the pharmaceutical industry." They're supposed to lower drug costs; instead, they're responsible for raising them.