Bryan R. Fine, MD, MPH

The market sets physician reimbursement rates in healthcare, right? WRONG. Here's how they're actually set. (It's closer to Soviet-era price-setting than a free market.) Back in the day, physician reimbursement was governed by the Customary, Prevailing, and Reasonable (CPR) charge system – but it wasn’t perfect, leading to: · Inconsistent pay across similar services · Geographic disparities · Inflated procedure costs · Underpaid complex office visits · Ineffective Medicare cost control In 1992, Relative Value Units (RVUs) emerged to address these issues. [4] RVUs aimed to standardize payments based on required resources, accounting for: · Physician's work · Practice expenses · Malpractice insurance Sounds reasonable, but it's not that simple. 👍 𝗣𝗿𝗼𝘀 𝗼𝗳 𝗥𝗩𝗨𝘀 1. Consistent basis for comparing medical services 2. Account for skill, time, and resources 3. Periodic reviews by the RUC [1] 👎 𝗖𝗼𝗻𝘀 𝗼𝗳 𝗥𝗩𝗨𝘀 1. Often lag behind current practices and technologies 2. Critics argue they overvalue procedures and undervalue counseling 3. Complex calculation confuses many physicians [1] 𝗤: 𝗪𝗵𝗮𝘁 𝗮𝗿𝗲 𝘁𝗵𝗲 𝗮𝗹𝘁𝗲𝗿𝗻𝗮𝘁𝗶𝘃𝗲𝘀? 1/ Value-based payment models These focus on patient outcomes rather than service volume. Including: · Accountable Care Organizations (ACOs) - a group of providers working together to give coordinated, high-quality care. · Bundled payments - one payment for all services related to a treatment. · Pay-for-Performance - providers get rewarded for meeting specific quality and efficiency measures. [1][2] 2/ Quality Metrics (e.g., HEDIS) This is about looking at the bigger picture of care, not just counting procedures. This includes: · Implementation of patient satisfaction scores · Clinical Outcomes - how effective was the treatment? Did the patient get better? · Efficiency measures - how much bang are we getting for our healthcare buck? These metrics could complement or even replace RVUs. The goal is to measure what matters (outputs), not just treatment (inputs). [1][2] 3/ Global RVUs They cover all healthcare services across hospitals, outpatient facilities, and home health services – not just physicians. Global RVUs aim to fix some of the limitations of traditional RVUs by giving us a broader view of service costs. [3] 4/ Telehealth and non-face-to-face services COVID-19 threw us into the deep end of telemedicine. But our old RVU system wasn't built for it. We need new models that recognize the value of care coordination, patient education, and preventive services that don't happen face-to-face. [1][2] Looking forward: We're moving towards personalized, tech-driven healthcare, and our reimbursement models must keep up. Imagine a system that considers not only the complexity of care (like RVUs) but also factors in outcomes, patient satisfaction, and innovative technologies. We can't have outdated payment models holding back medical progress.

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ICYMI: I wrote about HCA Healthcare's Q3 results. Here's a nifty one-pager for LinkedIn and what you missed in Hospitalogy: Volume + Utilization: • Another quarter of broad-based growth. OP surgeries down (from Medicaid/Uninsured), but revenue increased 5% (acuity & payor mix grew 7% to counteract the decline). HCA specifically called out cardiac procedures, rehab, and obstetrics in prepared remarks on the earnings call itself.   Medicare vs. MA: • Same-facility Medicare admissions grew 5.3%. Traditional Medicare was flat. MA admissionsgrew11%inQ3; HCA attributed 2% of this growth to the 2-Midnight Rule.   • Same-facility adjusted admissions declined 8.5% in Medicaid, increased ~4% in commercial, and increased 43% in exchange. Uninsured adjusted admissions increased +7.2%.   Revenue + Payor Mix: • 7.1% = Same-facility revenue growth. 7.9% overall revenue growth. ‘Modest’ benefit from Medicaid supplemental payment programs.   TOO MANY DENIALS: • Point of emphasis for all hospitals in 2024. HCA has seen ramp-up in payor denial activity but didn’t see a $$$ impact. Still, HCA observed a few large MA players driving the most denials. MA patients have higher LOS (around 10% higher) even adjusting for acuity. HCA blamed but is working with payors on this inefficient dynamic.   Expenses + Margin: • 0.9% increase in adj. EBITDA from improved labor (down 1.6% as a % of revenue) and contract labor (4.6% of total labor spend, down 18% over 2023). 2.5% - 3.5% wage increases for 2025. Supplies & other operating expenses squeezed revenues a bit. HCA sees opportunity with AI and other investments to improve admin functions. It recently announced an expanded partnership with Commure to deploy ambient AI system-wide.   Capital Allocation + CAPEX: • ~$1.2B in CAPEX in the quarter. ~$1.8B in share repurchases and ~$170M in dividends distributed. HCA plans to have added 600 IP beds and 100 new OP facilities by the end of 2024. $6B in capital projects under development. 2,600 sites of care by the end of 2024.   Outlook + Guidance: • HCA thinks elevated volume growth will continue at 3% - 4% while reimbursement will increase 2% - 3%, resulting in growth ‘near or slightly above’ long-term HCA targets in 2025. $50M or $0.15/share lost estimate from hurricanes in Q3. Exchange growth will moderate in 2025 to 8% - 10% vs. 30% in 2024 (commentary prior to election results).   My Take: • While we may have reached peak ‘hospital multiple’ HCA continues to benefit from a strong & stable operating environment entering 2025 in its markets: broad-based growth with ‘very few challenges.’ Expect HCA to continue to win IP market share over less efficient competitors as it drives toward having 13, and more like 17 to 20 access points per hospitals in its selected markets.

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AVAILABLE: This 77-second video introduces a Greater Atlanta (onsite) or remote Revenue Cycle Optimizer, who I'm pleased to represent. She has: - Large Health System Experience (on the ProFee side) - ID'd and released $1M worth of unposted charges that were caught in EMR - Helped reduce AR by $200K with the review of incorrectly billed charges Contact me privately for information, or please pass this long to someone who might be in need of this type of talent. Cheers! Grant NOTE: Images are iStock Getty Images chosen as representations of the individual referenced to assure her initial confidentiality (I can reveal in private inquiry). #healthcarefinance #healtheconomics #recruitment #recruiting #medicalbilling #medicalcoding #healthcarerecruitment #healthcarejobs #medicalbillingcompany #hospitalmanagement #hospitaladministration #hospitalbilling

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I have seen a number of posts encouraging physicians and providers to switch to a cash pay/direct model. I am all for it; it's not the direct model that frustrates me, but it is the motive and reasoning. Many say there are so many healthcare service providers and vendors (with an emphasis on RCM companies) that eat away at the profits of the physicians, and its better to be direct to get away from us, so-called, leaches. I think there is a big misunderstanding. RCM companies and other vendors add value to the healthcare organizations - and if they didn't, they would not be in business today. Companies adding value and delivering service in exchange for a profit are not leaches, however...there is a villain, two actually: 1. The education and conditioning that physician practices/hospitals exist only to deliver care 2. The big name firms that fall into two categories. Category I: the firms that reimburse providers and Category II: The large tech firms that siphon your data for free based on "doing good for the world." Let's dive a little deeper. Just pretend for a minute you are a physician or provider (hopefully some reading this are). What if there was a black box that had at least 50% of the information and data you would need to statistically predict how you should treat a patient, predict when you would get paid, predict how much you would get paid, predict how many staff you need, etc. - the possibilities are endless, right? You probably know what I am talking about...the EMR. Now, think about what makes you as a provider different. Probably, the way you practice is different enough that your data would show more value for at least a selection of services than the median of your competitors. What if we could quantify that "extra value" in terms of "savings" that your practice delivers to the payers, perhaps, that might assist in negotiating better reimbursements? What if we could connect your other systems and EMR to automate revenue recognition, predict future cash collections, manage AR and denials in real-time, automate scheduling and staffing, etc. and all of this was rolled into an executive dashboard on an app that you can open on your phone in the "background" of YOUR own IT environment so: 1. YOU retain full ownership/control of YOUR data 2. No one on your staff has to learn any new programs 3. You deliver exceptional personalized care based on YOUR patient's data and health history because the insurance carriers have used this data against you in negotiations for years Google & the big boys purchase it in bulk from the insurance companies and even get many HC orgs to "opt-in" to freely give them data to "make the world a better place" What if healthcare organizations finally realized the value of their business is their data Opilio's clients are waking up and benefitting greatly - so can you. (Btw I am all for making the world a better place but YOU should profit from YOUR expert systems, not a large tech firm.)

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Healthcare's $1 trillion problem is hiding in plain sight. It's not drug prices or insurance premiums. It's the humble phone call. Here's why: I've seen first-hand how physicians and their staff spend hours a day on the phone. Sometimes, it's for something as simple as a prior authorization request. But it adds up. Healthcare providers complete ~45 prior authorization requests per physician per week. That amounts to 14 hours (almost two business days!) completing those requests EACH WEEK. [1] So it’s not surprising our healthcare system is struggling with: 1. Staff burnout and attrition from repetitive, mind-numbing work 2. Skyrocketing costs 3. Patient outcomes that lag far behind other OECD countries What's maddening to me is that we are living at a point in history when AI can transform healthcare from reactive to proactive. Yet we're clinging to inefficient, error-prone, mind-numbingly boring methods. Phone call automation with AI can drive serious ROI: 1. Freeing clinicians to spend more time with patients 2. Reducing time-to-care and driving better health outcomes 3. Higher revenues from more efficient claim processing and a greater volume of patient encounters The future of healthcare isn't in a pill or a policy. It's transforming how we communicate. What's the biggest communication bottleneck in your healthcare organization? Is there an opportunity for AI to improve it?

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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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The annual ritual in which CMS proposes sharp cuts in Medicare reimbursement only to have Congress lift them at the last minute is a sort of public policy kabuki dance in which the outcome is practically preordained. Medicare reform is badly needed to end this cycle and put physicians on firmer footing so they can focus on what’s important: caring for patients. Read more at https://buff.ly/3Yo7iCs #radiology #medicalimaging #radiologists

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Hospitals, Medicare's 2030 goal is clear: 100% of payments in Value-Based Care (VBC). No one’s off the hook. CMS struggled to get specialists and hospitals into programs like Bundled Payments, so now participation is mandatory. Hospitals that resisted VBC have no choice. The Transforming Episode Accountability Model (TEAM) locks them into a system where every dollar is tied to patient outcomes. This isn’t a suggestion; it’s a mandate. Care coordination, cost control, and patient health are now non-negotiable. The era of fragmented care is ending. Hospitals must adapt or face the financial consequences. If you're navigating these changes and need a partner who understands the landscape, let’s connect. Medicare’s vision is clear, and the path to 2030 just got a lot more serious. https://lnkd.in/eT8GQqd4

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The US Physician Workforce will be decimated by the boomer doctor retirement cliff between now and 2030. A disturbing pattern in recent study findings makes this issue much more urgent - and the timeline to impact much shorter - than the government predictions. Let me show you why. The new statistics, the references ... everything The dots will all line up when you watch this short video and I'm happy to have the chance to show them to you. If you are a physician leader, this video is a Must-Watch because the mainstream media is not covering this phenomenon. Employers are only focused on short-term results: the numbers at the end of this second quarter, or the end of 2024.  They don't see this long-term trend. I also strongly recommend you share these videos with your C-suite - especially if your organization does not have a Corporate Wellness Strategy in place at this time. Learn what to watch out for - and what you must start doing now - to implement a Physician Wellness Strategy while there's still time. This trend will play out over the next three or four years. It's inevitable. You can't fight father time and nobody's getting any younger. Every doctor needs to know what is coming. Watch these short outtakes from this week's Wellness Champion Summit Webinar https://lnkd.in/gFYckWS4 **You will learn** 👉 What is the Boomer Doc retirement cliff? 👉🏽 How bad is it? 👉🏿 Recent changes in female physician and medical student behavior make things much worse. 👉 How the answer to this one question to your CMO doubles the projected physician shortage of 2030. 👉 Does AI at the same time make things better or worse? 👉🏿 What your organization must do now to prepare. 👉🏽 Why I'm predicting a brief window of opportunity for a corporate Physician Wellness Strategy - but you must act now!

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I'm trying to figure out why don't health plans offer multi-year contracts. Value to insurers: lock-in ARR / prevent customer churn. Value to members: insurance plan incentivized to pay for preventative care The best explanation I've heard why this doesn't happen came from Rebecca Mitchell, MD: Payers don't know how medical prices will inflate beyond a year, making pemium pricing / underwriting difficult. Surely this could be easier at an payvider though, yeah? I imagine the health plan at Kaiser could get better insight into future year physician contracts, hospital contracts, etc. Why else doesn't this happen today?

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I was looking at a RFP the other day for a Digital Health solution. There was not a single question about the company track record, clinical evidence or processes & playbook. The whole RFP looked like this: → Do you have feature X? → Do you have feature X? → Do you have feature X? → Do you have feature X? → Do you have feature X? So yes the RFP was almost certainly baked for another vendor. And maybe they do care about the other elements, but just really didn’t care to ask since it’s baked. But then I spoke to another health system recently that was evaluating several vendors and I asked them: 𝘞𝘩𝘢𝘵 𝘳𝘦𝘢𝘭𝘭𝘺 𝘮𝘢𝘵𝘵𝘦𝘳𝘴 𝘵𝘰 𝘺𝘰𝘶? Their answer: 𝘑𝘶𝘴𝘵 𝘵𝘩𝘦 𝘧𝘦𝘢𝘵𝘶𝘳𝘦𝘴 & 𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯𝘢𝘭𝘪𝘵𝘺. 𝘞𝘩𝘪𝘤𝘩 𝘮𝘦𝘢𝘯𝘴 𝘴𝘦𝘷𝘦𝘳𝘢𝘭 𝘷𝘦𝘯𝘥𝘰𝘳𝘴 𝘭𝘰𝘰𝘬 𝘵𝘰 𝘣𝘦 𝘱𝘳𝘦𝘵𝘵𝘺 𝘮𝘶𝘤𝘩 𝘰𝘯 𝘱𝘢𝘳 𝘸𝘪𝘵𝘩 𝘦𝘢𝘤𝘩 𝘰𝘵𝘩𝘦𝘳. Hmmm 🤔 Recently I also spoke to another health system which was already using a Digital Health product for several years, was getting frustrated with their current vendor and was now looking to switch. I asked the same question: 𝘞𝘩𝘢𝘵 𝘳𝘦𝘢𝘭𝘭𝘺 𝘮𝘢𝘵𝘵𝘦𝘳𝘴 𝘵𝘰 𝘺𝘰𝘶? Their answer: 𝘛𝘩𝘪𝘴 𝘵𝘪𝘮𝘦 𝘸𝘦 𝘸𝘢𝘯𝘵 𝘢 𝘳𝘦𝘢𝘭 𝘷𝘦𝘯𝘥𝘰𝘳 𝘱𝘢𝘳𝘵𝘯𝘦𝘳 𝘸𝘩𝘰 𝘢𝘤𝘵𝘶𝘢𝘭𝘭𝘺 𝘥𝘦𝘭𝘪𝘷𝘦𝘳𝘴 𝘰𝘯 𝘸𝘩𝘢𝘵 𝘵𝘩𝘦𝘺 𝘴𝘢𝘺 𝘵𝘩𝘦𝘪𝘳 𝘱𝘳𝘰𝘥𝘶𝘤𝘵 𝘤𝘢𝘯 𝘥𝘰 𝘢𝘯𝘥 𝘸𝘩𝘢𝘵 𝘵𝘩𝘦𝘺 𝘸𝘪𝘭𝘭 𝘥𝘰. 𝘞𝘩𝘰 𝘢𝘤𝘵𝘶𝘢𝘭𝘭𝘺 𝘩𝘢𝘴 𝘴𝘶𝘣𝘫𝘦𝘤𝘵 𝘮𝘢𝘵𝘵𝘦𝘳 𝘦𝘹𝘱𝘦𝘳𝘵𝘪𝘴𝘦 𝘰𝘯 𝘩𝘰𝘸 𝘵𝘰 𝘮𝘢𝘬𝘦 𝘶𝘴 𝘴𝘶𝘤𝘤𝘦𝘴𝘴𝘧𝘶𝘭 𝘸𝘪𝘵𝘩 𝘵𝘩𝘦 𝘵𝘦𝘤𝘩𝘯𝘰𝘭𝘰𝘨𝘺. Sometimes experience is the biggest teacher… although in healthcare, the challenge is we really don’t have time to waste. Probably every health system leader reading this will tell me their organization is in the latter example of this story, not the former. But I’m telling you, if you actually unpeel the layers… the former story of focusing on just the Tech and not the People and Process… is happening way more than you think in your organizations. And when you’re wondering why that piece of Tech you invested in doesn’t work… it might very well be that you focused on the wrong things in the initial vendor selection process. Agree or Disagree? #digitalhealth #healthcareinnovation

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 Another Medicare Cut for Physicians? Look to Congress, Not CMS — Medicare patients and providers deserve better The Medicare "conversion factor" (CF) -- a multiplier that is used to calculate payment rates for each service or procedure -- is lower than it has been in decades. This means even less reimbursement for many that serve Medicare patients. The proposed 2025 CF is so low that the last time we saw a lower CF was in 1993 When adjusted for inflation, Medicare physician payment has declined by 29% from 2001 to 2024. The inadequate pay rate is also contributing to ongoing problems with physician burnout. What other highly skilled professionals who have dedicated over ten years of their lives to training to become physicians would be willing to work tirelessly on behalf of patients and their care for a 29% pay cut? Congress needs to develop a workable solution versus the current approach to pay cuts for physicians every year consisting of throwing them a bone with meager increases to the CF. #betterpay, #physicanburnout, #Medicarepatientaccess, #paycut, #CFcliff . https://lnkd.in/etYZGNju

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Where are group practices in Atlanta? The map below shows two types of Medicare-enrolled providers: 1. PRACTITIONER - INTERNAL MEDICINE in red 2. PART B SUPPLIER - CLINIC/GROUP PRACTICE in green The bubble size shows the number of different NPIs around that area. I just finished geocoding all the NPPES data. After debating about what would be fun to explore, I decided to ask this question that has been bothering me for some time: "Where are group practices in Atlanta?" I live close to Emory Healthcare, and almost everyone I know works for Emory. I have always thought the Atlanta market was governed by giant health systems, not independent practices. After drawing the data on the map, I realized why I didn't see many group practices near my place. Many group practices are near the Sandy Springs/Dunwoody area. Surprisingly, that particular regional market seems to be the only one with "many" group practices. What's so special about that area? Is it because the area is "far enough" from the giant health systems in the city? Or is it because the population near there prefers to have some perks(?) only available from group practices? Funny enough, I was just there in the morning since I got pink eyes from my daughter, and that's where I could book an appointment almost immediately. #opendata #geocoding #marketmap

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A popular telemedicine website penalizes physicians if they don't get good customer satisfaction ratings. They then route the next consult to another physician with better ratings. The question is whether better customer satisfaction ratings of doctors equate to better clinical care. A business will usually make business decisions. And if a business isn't held to the same clinical standard as a physician then the outcome and impact on patient health should be evident.

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I've seen companies buy a "turnkey" RPM solution only to realize it can't sync data with their EHR system or runs on outdated tech the engineers hate. Then you're stuck doing expensive overhauls or ripping and replacing. But even there, I avoided turnkey offerings. Why? Because they're often bloated with features my team didn't need, and custom workflows were difficult to build. Instead, I chose to build our RPM devices and billing software from the ground up. It took way more time and money upfront, but it let us mold the tech to our audience’s exact clinical and operational needs with zero shoehorning. Was it a harder road? Yes. But now I'm not stuck paying heavy fees to customize a turnkey system. That's my philosophy - unless it's a dead simple commodity, forget turnkey. In healthcare, the upfront savings are rarely worth the debt. Build it custom or be prepared for a gut rehab down the line. As a founder, what’s your take on the turnkey model? ♻️Repost to gather more insights. #founder #turnkeymodel #tips #healthcare

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🏜️𝗘𝗛𝗥𝘀 𝗔𝗿𝗲 𝗗𝗮𝘁𝗮 𝗗𝗲𝘀𝗲𝗿𝘁𝘀: 𝗪𝗶𝗹𝗹 𝗔𝗜 𝗣𝗿𝗼𝘃𝗲 𝘁𝗼 𝗕𝗲 𝗮𝗻 𝗢𝗮𝘀𝗶𝘀 𝗼𝗿 𝗮 𝗠𝗶𝗿𝗮𝗴𝗲? ⏱️As a physician, EHR's are frustrating. I find myself navigating vast data deserts every day within them. The majority of my time is spent aggregating and synthesizing data. This is a sentiment echoed by many in my field. ➡️According to a 2020 study by Cerner, physicians spend the majority of their EHR time on chart review, approximately 33% and another 24% dedicated to documentation. This significant investment of time highlights the inefficiencies currently embedded in clinician daily workflows. 💥𝗧𝗛𝗘 𝗛𝗬𝗣𝗘 The buzz around artificial intelligence (AI) suggests it could be the oasis we've been searching for, promising to streamline these processes. However, some recent publications urge us to temper our excitement. For instance, while AI can help summarize information, it also presents challenges, such as the generation of content by large language models (LLMs) that may actually increase the workload. Physicians now find themselves not only reading patient messages but also deciphering AI-generated content, which can sometimes be misleading due to the "hallucination" problem where AI fabricates or misrepresents data. ❌𝗧𝗛𝗘 𝗖𝗥𝗢𝗦𝗦𝗥𝗢𝗔𝗗𝗦 Despite these challenges, AI does hold promise. It has the potential to transform our interactions with data, provided it is implemented thoughtfully. It is crucial that we conduct careful objective, peer-review studies to ensure AI is used effectively, enhancing the lives of both physicians and patients without exacerbating current challenges. ✅𝗣𝗘𝗥𝗦𝗢𝗡𝗔𝗟 𝗘𝗫𝗣𝗘𝗥𝗜𝗘𝗡𝗖𝗘 𝗮𝗻𝗱 𝗖𝗛𝗘𝗖𝗞𝗣𝗢𝗜𝗡𝗧𝗦 For me, the jury is still out. While I have seen AI effectively summarize complex information, the ongoing issues of accuracy and reliability cannot be overlooked. As we move forward, our focus should be on understanding the appropriate use cases for this technology to ensure it serves as a true aid in our clinical decisions, not as a hindrance. ✅Here are my Personal Checkpoints for Useful AI 1️⃣ Accuracy➡️Trust: AI must demonstrate consistent accuracy and reliability, to earn my trust. 2️⃣Integration➡️Usability: AI should seamlessly integrate into existing my workflows, enhancing usability without complicating my already tedious workflow. 3️⃣Clinical Relevance➡️Impact: 𝗔𝗜 𝗶𝗺𝗽𝗹𝗲𝗺𝗲𝗻𝘁𝗮𝘁𝗶𝗼𝗻𝘀 𝗺𝘂𝘀𝘁 𝗵𝗲𝗹𝗽 𝗺𝗲 𝗺𝗮𝗸𝗲 𝗯𝗲𝘁𝘁𝗲𝗿 𝗱𝗲𝗰𝗶𝘀𝗶𝗼𝗻𝘀 𝗶𝗻 𝗹𝗲𝘀𝘀 𝘁𝗶𝗺𝗲. 𝗕𝗼𝘁𝘁𝗼𝗺 𝗹𝗶𝗻𝗲. 🤩Your thoughts and comments are appreciated. #artificialintelligenceinhealthcare #aiinhealthcare #ai #physicianburnout #healthcareinnovation #healthtech

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Understanding your health plan's prices or your managed care contract is a very challenging task. The multitude of variables in claim pricing is astounding. Zip codes, provider credentialing, past visits, diagnosis codes, and obscure administrative guidelines, etc. create significant difficulty in determining the contract prices and ultimately the sufficiency of those prices for your health plan or managed care contract. Network and HealthPlans guard their pricing methods as intellectual property. It is critical to understand the impact of the pricing system for everyone involved to reduce this industry wide cost of healthcare payments A network or payer provides the output of their pricing mechanism through the traditional claim's payment process. Using the site specific, Medicare index for each code or DRG will allow a health plan or healthcare provider to determine what the sufficiency and payment adequacy for their claims and procedures. Even when the plan uses an alternative or proprietary pricing index, a Medicare index analysis gives you the information necessary to evaluate your health plan or contract prices. For certain, this Medicare index process is much easier to use and evaluate versus a machine-readable file! The cost of not understanding and using a Medicare index for all healthcare plans and provider contracts arises in the continual high (and higher!) cost of healthcare payments. Unnecessary claim appeals, phone calls, legal expenses and credit balances underscore the need to reconcile the prices for healthcare at your employer plan, medical provider, and insurance company. Imagine the wasted costs involved in trying to resolve healthcare payments between health plans, providers, employers and various ERISA plans. Is it about time we change the cost of healthcare payments?

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The 1 reason lowering healthcare costs is so hard: That $4.5T in healthcare spend? That's someone else's revenue VCs don't want to shrink the pie PE doesn't want to shrink the pie Insurers don't want to shrink the pie Hospitals don't want to shrink the pie Pharma doesn't want to shrink the pie Med device companies don't want to shrink the pie How do they grow when the industry retracts? They don't That's the fundamental issue P.S. Interested in more financial mind benders to understand how the financial incentives in healthcare hold us back? Check out The Healthcare Breakdown: https://lnkd.in/gVRtQGZN We talk about this stuff See you out there!

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