Practice Management

My frustration with the way Texas has implemented their Balance Billing regs has lead me to drafting the attached comments which are being shared with appropriate individuals that can influence Texas rulemaking or policy development.

You have to wonder if some of the rulemaking by the Texas Dept of Insurance was intentional to dissuade providers from filing for arbitration.

With that said, I share these comments for 2 reasons:

1. To encourage other Texas practices to voice their concerns with the TDI, TMA, TXMGMA, whomever will listen.
2. Additionally, to provide the RBMA with comments before the Federal rulemaking ceases.

Bob - not sure who is on the legislative committee - but if you can provide these comments, I'd appreciate it.
Some comments on attached are specific to Texas.
Others may be applicable at the Federal level:

1. A process to upload claims in batches via .txt file vs. a manual entry on some website.
2. A process wherein the 835 file has specific CARC to designate state vs. federal health plans.
3. The ability to batch claims by the group NPI, not the individual provider NPI.

Exhibit B was excluded for this audience as it was more relevant for Texas only.
I uploaded my comments, not sure if you can see them in this post or have to go to another spot on the RBMA website.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
------------------------------

Based here in GA and will be working through our Surprise Billing legislation too.

What caught my attention on the attached was Ambetter.  Don't now if this was simply a placeholder or the actual payer which you were submitting to the TDI.  I will be pursuing the same payer.  Appears Ambetter has a contracting strategy of not contracting.  Then they process the claims at 100% of Medicare.  I've reached out numerous times to their contracting folks and can't get a return email or call.  Not wanting to put pts in the middle of this issues, we are being forced to pursue a solution via the GA DOI and our recently passed Surprise Billing legislation.

I didn't know if the payer name Ambetter was used in other states.  Ambetter is the commercial product of Centene Corporation.  You probably have a Medicaid HMO product in your state which is actually part of Centene Corporation.  For example, in GA we have Peach State owned by Centene Corporation.  When Ambetter contacts you they may suggest Ambetter is a Medicaid product.  It is not.  Ambetter is a commercial product.  It is sold via their website and healthcare.gov in Georgia.  Ambetter's premium is slightly lower than other payers selling through healthcare.gov.  However, there's no network supporting the product.  There are zero primary care providers in my area contracted with Ambetter.    But Ambetter is selling a product in my area.  

Good luck......Chris

------------------------------
R. Christopher Sluder CPA
Administrator
Rome Radiology Group
Rome GA
(706) 291-2661
------------------------------

Original Message:
Sent: 05-24-2021 14:55
From: Douglas Kraus
Subject: Balance Billing

My frustration with the way Texas has implemented their Balance Billing regs has lead me to drafting the attached comments which are being shared with appropriate individuals that can influence Texas rulemaking or policy development.

You have to wonder if some of the rulemaking by the Texas Dept of Insurance was intentional to dissuade providers from filing for arbitration.

With that said, I share these comments for 2 reasons:

1. To encourage other Texas practices to voice their concerns with the TDI, TMA, TXMGMA, whomever will listen.
2. Additionally, to provide the RBMA with comments before the Federal rulemaking ceases.

Bob - not sure who is on the legislative committee - but if you can provide these comments, I'd appreciate it.
Some comments on attached are specific to Texas.
Others may be applicable at the Federal level:

1. A process to upload claims in batches via .txt file vs. a manual entry on some website.
2. A process wherein the 835 file has specific CARC to designate state vs. federal health plans.
3. The ability to batch claims by the group NPI, not the individual provider NPI.

Exhibit B was excluded for this audience as it was more relevant for Texas only.
I uploaded my comments, not sure if you can see them in this post or have to go to another spot on the RBMA website.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
------------------------------

Chris, it was not an accident their name was listed.
Our experience has been much the same as yours and coincidentally as I submitted our arbitration case for the first of many claims with them, someone reached out for a contract.

I simply copied the last email exchange I had with them not less than 6 months ago and once again indicated if we can't get past the insane rates their is no need to discuss a contract further.

I'll  take every last claim to arbitration if I have to. What annoyed me even more was once I started downloading the data from our practice management system to be able to file the arbitration case, I noticed some rather egregious payment trends.  

I suspect they are doing the same to most unsuspecting practices and more people need to fight their tactics as you are.

As I understand their Ambetter product, it's an ACA plan and yes, they have a MAP and Medicaid HMO as well.

Keep on fighting and as the Georgia legislation progresses keep in mind these nuances that can be a barrier to filing:
Must have the ability to upload data in batch vs. manual entry.
Must be able to file by group NPI, not individual provider NPI - this in itself makes filing for arbitration a money loser in 80% of the cases because you can not aggregate enough claims together for their to be a payback.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
------------------------------

Original Message:
Sent: 05-25-2021 08:54
From: R. Christopher Sluder
Subject: Balance Billing

Based here in GA and will be working through our Surprise Billing legislation too.

What caught my attention on the attached was Ambetter.  Don't now if this was simply a placeholder or the actual payer which you were submitting to the TDI.  I will be pursuing the same payer.  Appears Ambetter has a contracting strategy of not contracting.  Then they process the claims at 100% of Medicare.  I've reached out numerous times to their contracting folks and can't get a return email or call.  Not wanting to put pts in the middle of this issues, we are being forced to pursue a solution via the GA DOI and our recently passed Surprise Billing legislation.

I didn't know if the payer name Ambetter was used in other states.  Ambetter is the commercial product of Centene Corporation.  You probably have a Medicaid HMO product in your state which is actually part of Centene Corporation.  For example, in GA we have Peach State owned by Centene Corporation.  When Ambetter contacts you they may suggest Ambetter is a Medicaid product.  It is not.  Ambetter is a commercial product.  It is sold via their website and healthcare.gov in Georgia.  Ambetter's premium is slightly lower than other payers selling through healthcare.gov.  However, there's no network supporting the product.  There are zero primary care providers in my area contracted with Ambetter.    But Ambetter is selling a product in my area.

Good luck......Chris

------------------------------
R. Christopher Sluder CPA
Administrator
Rome Radiology Group
Rome GA
(706) 291-2661

Original Message:
Sent: 05-24-2021 14:55
From: Douglas Kraus
Subject: Balance Billing

My frustration with the way Texas has implemented their Balance Billing regs has lead me to drafting the attached comments which are being shared with appropriate individuals that can influence Texas rulemaking or policy development.

You have to wonder if some of the rulemaking by the Texas Dept of Insurance was intentional to dissuade providers from filing for arbitration.

With that said, I share these comments for 2 reasons:

1. To encourage other Texas practices to voice their concerns with the TDI, TMA, TXMGMA, whomever will listen.
2. Additionally, to provide the RBMA with comments before the Federal rulemaking ceases.

Bob - not sure who is on the legislative committee - but if you can provide these comments, I'd appreciate it.
Some comments on attached are specific to Texas.
Others may be applicable at the Federal level:

1. A process to upload claims in batches via .txt file vs. a manual entry on some website.
2. A process wherein the 835 file has specific CARC to designate state vs. federal health plans.
3. The ability to batch claims by the group NPI, not the individual provider NPI.

Exhibit B was excluded for this audience as it was more relevant for Texas only.
I uploaded my comments, not sure if you can see them in this post or have to go to another spot on the RBMA website.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
------------------------------

We're working on expanding our network participation in anticipation of the federal surprise billing law to avoid the arbitration process.  But we plan to use arbitration for Ambetter claims due to the low rates in Kansas.

------------------------------
Amber Stephenson
Office Manager
Manhattan Radiology
Manhattan KS
(785) 539-7641
------------------------------

Original Message:
Sent: 05-25-2021 10:04
From: Douglas Kraus
Subject: Balance Billing

Chris, it was not an accident their name was listed.
Our experience has been much the same as yours and coincidentally as I submitted our arbitration case for the first of many claims with them, someone reached out for a contract.

I simply copied the last email exchange I had with them not less than 6 months ago and once again indicated if we can't get past the insane rates their is no need to discuss a contract further.

I'll  take every last claim to arbitration if I have to. What annoyed me even more was once I started downloading the data from our practice management system to be able to file the arbitration case, I noticed some rather egregious payment trends.

I suspect they are doing the same to most unsuspecting practices and more people need to fight their tactics as you are.

As I understand their Ambetter product, it's an ACA plan and yes, they have a MAP and Medicaid HMO as well.

Keep on fighting and as the Georgia legislation progresses keep in mind these nuances that can be a barrier to filing:
Must have the ability to upload data in batch vs. manual entry.
Must be able to file by group NPI, not individual provider NPI - this in itself makes filing for arbitration a money loser in 80% of the cases because you can not aggregate enough claims together for their to be a payback.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.

Original Message:
Sent: 05-25-2021 08:54
From: R. Christopher Sluder
Subject: Balance Billing

Based here in GA and will be working through our Surprise Billing legislation too.

What caught my attention on the attached was Ambetter.  Don't now if this was simply a placeholder or the actual payer which you were submitting to the TDI.  I will be pursuing the same payer.  Appears Ambetter has a contracting strategy of not contracting.  Then they process the claims at 100% of Medicare.  I've reached out numerous times to their contracting folks and can't get a return email or call.  Not wanting to put pts in the middle of this issues, we are being forced to pursue a solution via the GA DOI and our recently passed Surprise Billing legislation.

I didn't know if the payer name Ambetter was used in other states.  Ambetter is the commercial product of Centene Corporation.  You probably have a Medicaid HMO product in your state which is actually part of Centene Corporation.  For example, in GA we have Peach State owned by Centene Corporation.  When Ambetter contacts you they may suggest Ambetter is a Medicaid product.  It is not.  Ambetter is a commercial product.  It is sold via their website and healthcare.gov in Georgia.  Ambetter's premium is slightly lower than other payers selling through healthcare.gov.  However, there's no network supporting the product.  There are zero primary care providers in my area contracted with Ambetter.    But Ambetter is selling a product in my area.

Good luck......Chris

------------------------------
R. Christopher Sluder CPA
Administrator
Rome Radiology Group
Rome GA
(706) 291-2661

Original Message:
Sent: 05-24-2021 14:55
From: Douglas Kraus
Subject: Balance Billing

My frustration with the way Texas has implemented their Balance Billing regs has lead me to drafting the attached comments which are being shared with appropriate individuals that can influence Texas rulemaking or policy development.

You have to wonder if some of the rulemaking by the Texas Dept of Insurance was intentional to dissuade providers from filing for arbitration.

With that said, I share these comments for 2 reasons:

1. To encourage other Texas practices to voice their concerns with the TDI, TMA, TXMGMA, whomever will listen.
2. Additionally, to provide the RBMA with comments before the Federal rulemaking ceases.

Bob - not sure who is on the legislative committee - but if you can provide these comments, I'd appreciate it.
Some comments on attached are specific to Texas.
Others may be applicable at the Federal level:

1. A process to upload claims in batches via .txt file vs. a manual entry on some website.
2. A process wherein the 835 file has specific CARC to designate state vs. federal health plans.
3. The ability to batch claims by the group NPI, not the individual provider NPI.

Exhibit B was excluded for this audience as it was more relevant for Texas only.
I uploaded my comments, not sure if you can see them in this post or have to go to another spot on the RBMA website.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
------------------------------