Relentless Health Value Podcast

Enhancing Payment Integrity in Health Systems: An In-depth Discussion with Kimberly Carleson.

In Episode 481 of Relentless Health Value, host Stacey Richter speaks with Kimberly Carleson, CEO of US Beacon, about payment integrity within health systems. They delve into strategies some hospitals use to maximize revenue without raising rates and discuss the importance of accurate billing. 

Key takeaways include the high prevalence of billing errors, which can lead to significant overcharges for plan sponsors, often due to documentation gaps and complex coding systems. Kimberly provides actionable advice for both healthcare providers and plan sponsors on how to mitigate billing inaccuracies and enhance transparency. 

Emphasized points include the necessity of third-party claim audits, understanding legal rights under various acts, and the importance of maintaining clear communication and compliance with legal billing standards.

=== LINKS ===
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08:36 What’s the magnitude of the lack of payment integrity within healthcare?

12:11 EP285 with Dawn Cornelis.

12:46 How is lack of coordination a main culprit of lack of payment integrity?

13:42 How does reading the records reveal whether health plans are being overcharged?

15:43 A real-world example of how reviewing the charges can drastically reduce your healthcare costs.

18:32 Do you have a right to a review of your claim?

19:37 EP370 with Erik Davis and Autumn Yongchu.

22:08 How can contracts contradict what can legally be charged?

23:46 EP472 with Eric Bricker, MD.

25:04 How can hospitals update their billing to have better payment integrity?

28:44 Advice for hospital executives and their finance teams.

29:03 Advice for plan sponsors.

Exploring the Complexities of Pharma Rebates with Ann Lewandowski

In this Summer Short episode of Relentless Health Value, host Stacey Richter converses again with Ann Lewandowski about the intricate dynamics of pharmaceutical rebates, or as Lewandowski prefers, post-sale concessions. 

The discussion delves into the nuances of these rebates, the impact they have on drug costs, and the hidden consequences for patients and plan sponsors. 

They highlight articles and insights by Austin Chelko and Peter Hayes, touching on how rebates can disadvantage the pursuit of lower-cost generics and biosimilars, and can obstruct pharmacogenetic testing that ensures drug efficacy and safety. 

The conversation also critiques the opacity of rebates, deemed trade secrets by pharma and PBM companies, and underscores the ethical and financial dilemmas posed by the current rebate-driven system.

=== LINKS ===
🔗  Show Notes with all mentioned links:  
https://cc-lnk.com/EP480

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07:24 What is a pharmaceutical rebate?

08:15 Why are pharma rebates so opaque?

09:52 Texas lawsuit on insulin pricing.

10:18 Why is focusing on a singular type of concession difficult with current pharma rebate structures?

10:50 EP397 with Paul Holmes.

13:55 EP353 with Pramod John, PhD.

14:29 How does pharma genomics testing affect pharma rebates?

14:52 EP465 with Chris Crawford.

15:52 EP426 with Nina Lathia, RPh, MSc, PhD.

In this second discussion with Andreas Mang and Jon Camire of Blackstone, Stacey Richter has  an advanced discussion on the intricacies of stop-loss reinsurance for high-cost claimants. 

This show today, for sure, it’s for plan sponsors and anyone on or about plan sponsors; but also listen if you are serving high-cost claimants some other way. Because what you’ll learn here today is some insights relative to how plan sponsors go about making sure that they can pay you—like if you work for, for example, some clinical organization.

There’s a, I don’t know, 101 starting point of this conversation if you need it on stop-loss, which is episode 478 from a couple of weeks ago. This show is the, let’s say, 201-level conversation that I’m having with Andreas Mang and Jon Camire about, as I said, stop-loss insurance and stop-loss insurance considerations.

Emphasizing the importance of eligibility audits and aggregating buying power, the guests highlight best practices to avoid overpaying for coverage and ensuring comprehensive risk management.

This episode is sponsored by Havarti Risk, which I am so thankful for. The show, Relentless Health Value, actually does cost an unexpectedly large sum of money to create and produce; so I always appreciate when somebody offers to sponsor a show or help sponsor a show.

=== LINKS ===

🔗  Show Notes with all mentioned links:

https://cc-lnk.com/EP479

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07:47 What are the best practices for plan sponsors to use for stop-loss coverage?

10:11 What are the “unknown unknowns” within stop-loss coverage?

15:25 What are some policy provisions that plan sponsors should be aware of?

19:02 Why is it so important to do eligibility audits?

20:41 What are some common mistakes made with stop-loss coverage among the self-insured?

23:21 What’s a panel approach, and why is it important for negotiating stop-loss coverage?

Stacey Richter has a second take on the original episode 433 since it is so relevant right now. Stacey engages in a compelling conversation with Justin Leader, CEO of BenefitsDNA, about the opaque practices of third-party administrators (TPAs) and their impact on healthcare costs. 

They discuss the hidden fees tucked into weekly claims wires, including shared savings fees, prior authorization fees, prepayment integrity fees, pay and chase fees, and TPA adjudication fees. 

The episode emphasizes the need for transparency, understanding hidden costs, and ensuring fiduciary responsibility for self-funded employers. Additionally, Leader shares insights from a Health Affairs article and mentions ongoing legal cases that highlight the financial discrepancies in TPA practices.

=== LINKS ===

🔗  Show Notes with all mentioned links:  

https://relentlesshealthvalue.com/episodes

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:

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🫙  Support the podcast with a small donation to the Tip Jar:

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🎤  Listen on Apple Podcasts  https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

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06:32 EP457 with Cynthia Fisher.

06:56 How is the claims wire typically explained to a plan sponsor?

10:49 What is the whole point of self-funding?

10:58 Why is it so vital to understand what you’re paying for?

11:53 What are the five “buried” items that wind up in these claims wires?

12:12 What is a shared savings fee?

16:14 “Rates are important, but so are your rights.”

20:13 What’s going on with prior auth fees?

22:44 What is prepayment integrity?

27:29 What is pay and chase?

28:46 EP428 with Julie Selesnick.

30:58 What is a TPA claim review?

33:21 EP285 with Dawn Cornelis.

34:16 EP379 with AJ Loiacono.

34:45 Is there medical claim spread pricing?

Host Stacey Richter discusses the intricacies of stop-loss coverage with Andreas Mang and Jon Camire from Blackstone. The episode focuses on defining stop-loss insurance and exploring its critical role in protecting self-insured employers from catastrophic financial losses. 

The conversation delves into the nuances of individual and aggregate stop-loss policies, laser claims, and the importance of selecting an experienced consultant to navigate this complex landscape. The episode is essential listening for those managing high-cost claimants and exploring self-insurance options.

This is a two part show. The second show will cover major fails, mistakes that happen with stop-loss when somebody doesn’t understand or do everything that we talk about. So, tune back in for the next part of this conversation, in two weeks.

Thank you to Havarti Risk for sponsoring this weeks episode. 
Havarti Risk empowers healthcare leaders like you to make smarter
decisions that increase quality and lower cost of care.
https://havarti-risk.com/

=== LINKS ===

🔗  Show Notes with all mentioned links:  

https://relentlesshealthvalue.com/episodes

✉️  Enjoy this podcast? Subscribe to the free weekly newsletter:

https://relentlesshealthvalue.com/join-the-relentless-tribe

🫙  Support the podcast with a small donation to the Tip Jar:

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🎤  Listen on Apple Podcasts 

https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1

🎤  Listen on Spotify 

https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b

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07:24 What is stop-loss?

08:27 What is reinsurance?

09:57 EP420 with Ge Bai, PhD, CPA.

10:10 Why has stop-loss been a barrier for smaller companies going self-insured?

13:55 Why self-insurance needs to be a joint decision between finance and HR.

15:38 What is aggregate versus individual within stop-loss?

19:51 Why is it important for companies to choose the right level of stop-loss coverage?

21:29 What is a laser claim?

29:28 Why is it important to know what your brokers are getting paid on your stop-loss policies?