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 ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP480
✉️ 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:
https://relentlesshealthvalue.com/join-the-relentless-tribe
🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
✭ X https://twitter.com/relentleshealth/
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.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Episode 480.
" Payment Integrity Meets HealthSystem Boasts, Such as Our Rates
Are 2x Medicare, and CarriersWho Also Have Medicare Advantage
Contracts." Today I speak with Kimberly
Carleson.
(00:24):
American Healthcare Entrepreneurs andExecutives, You Want to Know, Talking.
Relentlessly Seeking Value.
You know that episode from this springwith Eric Bricker about stop-loss
provisions as a way for some hospitalsso inclined to make more money without
technically at least raising rates likethey can substantially increase the
(00:46):
overall revenue from plan sponsors,the ones not paying attention at
least, while still able to claim theyare net net 0% increase or are very
much still 2x Medicare, for example.
Well, today we stumble on a few morestrategies to do the same thing in
the show today with Kimberly Carleson.
So spoiler alert.
(01:07):
Now look, all this matters.
It big time matters.
Anything that has to do with healthsystems and their billing of plan
sponsors matters because as we haveheard from multiple guests multiple
times, the shows with Shawn Gremminger,Cora Opsahl, Claire Brockbank,
Marilyn Bartlett, to name a few.
We have heard over and over againthat usually almost 50% of plan
(01:29):
sponsor costs have something to dowith members going into the hospital
and or getting care somewhere thatis under a hospital's umbrella.
50%.
And today we learn that up to80% of hospital bills may contain
some error with 25 to 30% ofthose errors being significant.
I just asked AI and it said thatapproximately five to 10% of total
(01:53):
hospital spend by plan sponsorsmight be attributable to billing
inaccuracies or excessive charges.
My guest today, as I have mentionedtwice already, Kimberly Carleson also
mentions a few stats about just themagnitude of some of these mistakes.
I mean, five to 10% of 50% oftotal spend, is a lot of money.
Okay, so let's discuss what we discusstoday, Kimberly Carleson and I. We start
(02:16):
out kind of digging into the where, why,and how many of these errors come to be.
Then we talk about some advice forthose who work at health systems
who may be interested for real inredressing some of the stuff that we
discuss and this whole conversation.
And also Kimberly's advice for healthsystem leaders is particularly relevant
for anybody looking to do directcontracting with plan sponsors, of course.
(02:39):
Because yeah, with a carrier in themiddle of some of this stuff, it might
not be entirely clear to many plansponsors, the magnitude or the member
impact of these billing mistakes.
However, in a direct contract,yeah, expect eyes on, so it
certainly would make good sense toget ahead of some of this stuff.
As I don't know, I know nothing really,but after talking to Kimberly and after
(03:01):
talking with Dawn Cornelis a few yearsago, for sure, some of this stuff can
be chalked off to weird complexitiesand not repeatable kinds of excusable
mistakes, but a good deal of it kindof seems like, how shall I say this?
Preventable.
It seems to fall into a categoryof why is this happening and
it's pretty darn obvious it's aproblem, and yet it still persists.
(03:22):
Where this conversation heads nextis getting into advice for plan
sponsors, which I will summarize foryour convenience right now, and maybe
add a couple of supplementary points.
Advice for plan sponsors that comes up inthis conversation with Kimberly Carleson,
number one, and this is a biggie,have a third party audit of claims.
(03:42):
The point comes out pretty clearlyin this show, but in that earlier
episode I mentioned the onewith Dawn Cornelis it also, this
point comes out just as strongly.
And right now in the timespace continuumin 2025, I don't know how you could
even argue with it, get a third partyto audit your claims, who isn't owned
by the same company as your ASO or TPAor whoever is processing the claims.
(04:04):
Julie Selesnick was on the pod lastspring and in that episode she says,
Look, it is the very definition ofa conflict of interest if you as a
fiduciary hire somebody and expectthem to accurately audit themselves.
On this exact same topic in that recentTake Two episode with Justin Leader
about The Mystery of the Weekly ClaimsWire, he talks about an example where
(04:26):
a TPA was using a branch of their owncompany to audit basically their own
claims, and they found $21,000 in errors.
This wasn't even enough to cover thefee for finding those errors, which
in this case was $25,000, right?
They spent $25,000 to find $21,000 total. Meanwhile, the employer, they then got
(04:47):
a third party in the mix who found allthe actual errors, and it summed up to
20 times that the third party auditorfound over $400,000 in errors that they
then recouped for the plan sponsor.
So yeah, first piece ofadvice for plan sponsors.
Don't do that.
Get a different payment integrity vendor.
You need somebody else toaudit claims other than the
(05:08):
person who is doing the claims.
Second piece of advice that comes upin the conversation that follows with
Kimberly Carleson, I'm just gonna giveyou the advice, but you need to listen to
the show to get the real full gist of it.
Contract amendments that the TPAor ASO or health plan that they
cannot negotiate to pay for chargesthat are not legally billable.
(05:31):
Right.
And this one is interesting for morethan just payment integrity purposes.
I'd say it's also interesting for directcontracting purposes and for TPA RFPs.
Again, Kimberly and I talk about thisat some length, and the whole thing
just reminded me of something that Ihad seen Dr. Cristin Dickerson write,
she wrote, "It is not just aboutwhat percentage of Medicare is paid.
(05:56):
It's about the codes charged.
While an imaging center may chargeone or two codes for an exam, I
see hospitals charging eight codes.
Those eight codes even paid at200% of Medicare are ridiculous."
This is just also, if you startthinking about it, why you gotta
watch it with those RBP contracts.
And, Dr. Dickerson gives a really goodexample of even if you have an expert who
(06:20):
limits code payments to some agreed uponamount, there are many cases where that
just doesn't work and hospital billingsystems are able to bypass the controls.
Now, what I just said is a little wonky.
If you didn't understand it, dolisten to the pod and then come back
and you will totally understand it.
But yeah, bottom line, don't accidentallyagree to pay for stuff that should
(06:44):
be free or shouldn't be billed forin the first place as per the law.
That is piece of advice two that comesup in the conversation that follows.
And then piece of advice three isknow your rights as a plan sponsor.
There is the CAA, theConsolidated Appropriations Act.
There is the no gag clauses rules.
Plan sponsors have an absolute rightto the itemized bill and they don't
(07:08):
have to pay until they get one.
And it is deemed clean.
Plan sponsors have a rightto the hospital contracts.
The TPA/ASO/health plan has negotiated.
And look, having a right and actuallygetting those rates which some deem a
trade secret are two different things.
So it is increasingly up to the plansponsor to run a clean RFP, request
(07:29):
for proposal, using best practiceslike Claire Brockbank talked about
in that episode from last fall.
If an RFP bidder clearly admits theydon't have transparent business processes,
or they have all kinds of trade secretsthat impede your access to transparent
information, and if they don't seemto be so inclined to change, then
it's on us really to exclude them fromthe RFP if they don't meet the terms.
(07:53):
Ann Lewandowski talked about this alittle bit in the whistleblower episode
from a few months ago, just how theDepartment of Labor definitely excuses
ERISA plans during a contract period whoare using a vendor who it turns out is not
doing things as per ERISA requirements.
But that leeway ends at contract renewal.
(08:16):
My guest today as aforementionedis Kimberly Carleson.
She is the CEO of US Beacon, wherethe mission is to meticulously
review and optimize medical bills.
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
Kimberly Carleson, welcometo Relentless Health Value.
It's a pleasure being here.
Thank you for having me.
What's the magnitude of the issues here?
(08:39):
You, you know, just obviously forthe members themselves, this can
be a catastrophic situation, butif I'm thinking about this from
the standpoint of the plan sponsor,what can you tell me about, you
know, if I said, eh, is it worth it?
What would you say?
For an example, in a review from oneclient we have, there was 55,000 members.
(08:59):
There's a $600 million medical spend.
We had identified 64 millionin excessive charges.
That's more than 10% of thetotal spend, and that was
just claims $10,000 and above.
A lot of us sit in chairs and it's justlike a million here, but $64 million.
(09:19):
That's a lot of money.
A lot of money.
And that was in one year?
One year.
Mm-hmm.
So, what are the most prominent ways thata health system, a hospital, may wind
up messing up a bill and overcharging?
So I think you havedocumentation, delays or gaps.
Physicians and clinicians may, theywork under tight constraints, so
(09:42):
documentation is delayed or incomplete.
Billing teams may make assumptions orapply standard charge protocols that don't
reflect what actually occurred, and thenyou've got, um, your manual data injuries
or your fat fingers that accidentallyhit a button that they didn't mean to.
It pulls the wrong code altogether,and so you're charged extra.
(10:03):
You've got unbundling services wheresome procedures may be billed in a
bundled charge, and then on the itemizedstatement, they're billed separately.
They pull out every singlecharge from that bundled charge.
You have upcoding.
Codes are sometimes assigned to ahigher level of complexity then what's
medically necessary or documented?
There's duplicate billing chargingfor, uh, non FDA approved items.
(10:25):
We had a pacemaker one time thatwas non FDA approved, and you can't
charge for that under CMS guidelines.
And then you've got inflated markupson routine items, time-based charges
without time documentations like inORs or recovery room, sometimes billing
services that weren't even rendered.
And then I think you have the lack ofcoordination between departments because
(10:45):
there's such a demand and the hospitalsystems are so packed and understaffed
that there's lack of coordination.
You have misuse of revenue codes,emergency room coding, details
that are not properly done, andthen repetitive charges on multiple
days that they're in the hospital.
So just kind of summing up whatyou, you said there, it sounds like.
(11:07):
I think my big takeaway from everythingyou just said is that it could be one of
many ways that, that this could happen.
I mean, it could.
That's just a few.
Yeah.
Yeah.
It was a pretty, prettycomprehensive list.
If that was just a couple of'em, um, I'm getting the drift.
Hi, I am Keith Passwater,CEO of Havarti Risk.
As a healthcare actuary, I cansometimes get deep into the weeds
(11:27):
of the math behind healthcare.
Maybe you experience that aswell, getting hyper-focused
to your corner of healthcare.
That's why I so appreciateRelentless Health Value.
Listen to the conversations reminds methat our healthcare system is huge, but
we're ultimately here for the patients.
If you wanna make a difference inhealthcare, don't miss an episode
of Relentless Health Value, and Ireally encourage you to follow the
podcast on Apple Podcast or Spotify.
(11:49):
And please leave a review.
Thanks for listening.
So, as you said, it could be just simplyfat fingers, just somebody messed up.
It could be, it sounds like a failureto communicate adequately, maybe
between like the clinical team andthe billing team, so somebody makes
an assumption that was not correct.
(12:11):
The bundling errors we had Dawn Cornelison several years ago, and this is one
of the things that she talked about alot, where, you know, if you're charging
a bundled price, you can't then go backand charge for the individual services
that are part of that bundle also.
You can just have duplicate billing,be it just a duplicate billing.
Or it could be if a, if it's an inpatientwho's in the hospital for multiple
(12:32):
days, they wind up charging for thesame thing multiple days in a row.
That should be one, as you said,time-based billing, you know, something
was for like in an OR whatever, andthat was not necessarily documented
or is inaccurate in some way.
I mean, I really don'tthink it's intentional.
I think it's just sometimes I don't.
Most of the time, I don't thinkit is, but it's just a lack of
coordination between departments andjust in a, everyone's in a hurry.
(12:56):
Hospitals are large, really complicatedentities with lots of stuff going
on and lots of different people.
And two, they change systems so much.
And then I'm sure also from theclinical side, like as a clinician,
you might not even realize what'sbeing done with what you're typing in.
Like you're trying to document whathappened in the clinical visit and
somebody else is gonna take thatinformation and do other things with
(13:19):
it, that now it's outside of yourpurview, what winds up happening
down that particular vector stream.
But before, before we get, I definitelywanna ask you for some representative
examples, maybe of all of this comingtogether in a way that is worthy
of talking about on this podcast.
But before we get there, let,let me ask you something.
(13:42):
How do you know this?
Like, are you actually talkingto members and they say, no,
I didn't have that in the ER.
Like, or whatever you know.
Well, the coding guidelines, Imean, if you know your coding and
you've been doing it long enough,you're aware of what can be charged.
You're aware of someone goesinto the ER for a stitch because
(14:05):
they fell and bumped their head.
They're not a level four ER visit.
They're a One or two, you know,so you know from the medical
records that this charge cannotbe escalated up to a level four.
So you just read the records.
So it's not just, you know, theyalways say, you know, absolutely
go and get an itemized bill.
Like we've had Marshall Allen on the,like, you can practically talk to no
(14:28):
one who won't tell you that the firstthing that to do here with any sort
of billing conundrum of almost anykind is to go get that itemized bill.
So can you just look at that itemizedbill and see that what the severity
is, or make some assumptions there?
I mean, some of the stuff that youwere talking about, definitely,
like if it's a duplicate charge orwhatever, if you get the itemized
(14:50):
bill, you would be able to tell.
But some of the stuff relative to theseverity of it, like wouldn't they just
code that it was a level four trauma andnot write down that it was one stitch.
Right?
You can absolutely see itfrom the itemized bill.
The itemized bill's gonna tell you ifthey had Tylenol or if they had codeine.
You know, it's going to tell you andyou're gonna be able to see exactly
what that patient went through atthe time they were in the hospital.
(15:13):
Let me just ask you for a couple ofdifferent examples here, and one of the
reasons why I'm for sure digging in onthis is just because we talk a lot on
this podcast about how much plan sponsorstend to spend on hospital charges.
You gave an example of a plan sponsorwhere almost 10% of charges were
(15:36):
inaccurate and could be recouped.
So because the dollars areso big, errors can be huge.
Can you just maybe run through justsome real world examples of a situation
that happened, just which may givelisteners a little bit of context here.
We had a lung transplant and it wasout of network, but it was a single
case agreement and it was 1.5 millionwas how much they were charging.
(16:00):
We were reviewing it and theycharged $676,000 for the organ.
You can't charge that for the organ.
You have to charge 56,000.
That's all, that is allowed by law.
So once we got done with that bill,it went from 1.5 million to 290,000,
and that's just ineligible charges.
We just eliminate whatlegally should not be there.
(16:23):
From CMS guidelines, NCCI edits, NUBC,AMA, Social Security Act, all of those
go into play with what we look at andit's just what legally is not owed.
So someone was trying to charge$600,000 less for something that they
should have charged 50 something.
So it's like 10, 12times what was allowable.
(16:44):
Yes.
So it's easy to see how these chargescan just add up and it's, it was
probably like their charge, mastercharge or whatever, and it almost
sounds like the re-pricer like failedto notice this or whatever happened.
But that bill made it all the waythrough the gauntlet and it was
ready to be paid or already paid.
I've seen implants be up to $30,000when they should have cost 6,000.
(17:08):
IV hydration therapy.
That is a big one.
You can't charge for saline in an IVthat goes within the hospital charge.
Operating room charges.
I even saw the other daycutting a pill, a pill cutter.
They charge like $20.
That's just slicing the pill in half.
Your recovery room charges, theydon't document the hours, so that
(17:30):
can be extremely overcharged.
Respiratory therapy services, if they'rebilled daily, it often lacks medical
necessity or for provider information.
You've got, oh, venina puncture whenthey put a needle into your arm.
They can't charge you for the push ofthe needle, and they do that a lot.
Uh, the EKGs are well known for duplicatebilling and charging excessively when they
(17:53):
should be within the bundled code itself.
Sterilization, I've seen it 19 times ona bill separated out, but sterilization
is bundled in a code within the surgery.
So that should never be separated.
Over the counter medication,that's not billable.
It's not legally billable.
You can't charge for Tylenol.
Implant components.
That's a huge one.
(18:14):
They're all bundled into a code.
You can't charge for each screw.
Again, as we all know, and I thinkyour examples indicate why it's so
important to get the itemized bill
Absolutely every time.
You have to go back and askfor the itemized and sometimes
they don't send it then.
You have to, it's verydifficult to get at times.
As a plan sponsor, do I have alegal right to get the itemized
(18:36):
bill or how does this work?
Absolutely.
You have a legal right under ERISA,the Consolidate Appropriations Act.
You have a right to review your documents,itemized statement UB-04 before it's paid.
But if they delay long enough, now all ofa sudden my member's getting nasty grams.
Like, how do you go about gettingwhat you need while, meanwhile
(18:56):
there's all this other, you know, I,I don't think the process probably
stopped that the, the hospital just'cause this is going on on the side.
Legally by law allowed to have a reviewof your claim and you want a clean...
Once you turn in a clean claim, thenthe 30 days for payment can go, the
clock can start ticking for payment.
We hound them with fax, emails,calling them in order to
(19:19):
get that itemized statement.
Most of the time a lot ofhospitals are compliant.
Most are, we know the ones that aren't.
So how the process typicallyworks is the plan sponsor is gonna
go ask for the itemized bill.
They may turn around and send yousomething else, like there's this UB-04
that gets brought up sometimes AutumnYongchu talked about this just kind of
(19:40):
general idea where there's itemized billsand then there's other documents that
at the end of the day still are roll-upsthat the hospital may respond with, which
actually do not give enough informationif you're trying to do a bill review.
So then you gotta turn aroundand say, no, no, no, no, no.
I want the actual itemized bill.
And you can cite theprecedents for getting it.
(20:00):
Do they have like a a period of timethat they must send the itemized bill
over in, or do you just say, you know, weain't gonna pay it until you get me the
itemized bill and therefore it's on themto choose how long they're gonna delay.
Each state is different.
We state those laws and we state howmany days they have and the date.
Usually you would have theallowable amounts, send it
(20:21):
back, and that's what you pay.
And typically, very few appealswhen you do it right, when you,
what's legally owed is paid.
So if a plan sponsor is up on theregs and, and knows how much, what,
you know, what the actual contractualallowable amounts are and a health
system is told, look, this is the drill.
This is what thesecharges should have been.
(20:43):
Then they're not like in the meantimefighting with you while they're sending
the member collection notices about thehigher amount or something like that.
Right.
And so most don't allow that.
As a bill re reviewer, youlet 'em know how, why you have
did not allow those charges.
Give them the chapter number, give 'emthe page number, whatever you have to do.
I just got one the other day and Ihave to send back the chapter number
(21:05):
of CMS guidelines, the page numberof why this cannot be charged.
But if you're a plan sponsor, what?
What does CMS have to do with this?
Those are the guidelines for billing.
The CMS guidelines is whatyou go off of the CPT codes.
Mm-hmm.
From the CMS, AMA, NCCI, all ofthose go into how much you're
legally and contractually owe.
Even as an ERISA plan?
(21:26):
Yes, even as an ERISA plan.
You cannot add the CPT code withanother CPT code that is supposed
to be all in the bundled CPT code.
Do you understand?
You can't break certain CPT codesout if they're bundled into one.
These are CMS regs.
Like if you're charging a bundlepayment, you can't just turn around
and charge all the things that areactually part of the bundle also.
(21:47):
There are other things, like you can'tcharge for sterilization multiple times.
You can't charge for pill splitting, youcan't charge for venipuncture, right?
Like these are all sort of part andparcel to what constitutes a code.
There's federal guidelines for coding.
Well, it's just interesting to methat some things do have those caps
on them, like 60k for an organ.
(22:07):
Well, and you know too, if anetwork has a contracted rate or a
negotiated rate, there's nothing youcan do about what is being charged.
If their contract says that theycan charge for robotics, then
they can charge for robotics.
And you're not really allowed tocharge for robotics because that's
integral to the hospital equipment.
Billing can be so confusing, and I canunderstand how hospitals are perplexed
(22:30):
when getting them out or making mistakesbecause it is very confusing and depending
on the provider and plan you have.
Also, are you saying that the lungtransplant that wound up costing,
you know, they were charging600,000 for a lung when it should
have been 50,000 for the lung.
Are you saying that sometimes, thecarrier, whoever, there's another
(22:52):
contract that would overridethat, those CMS guidelines.
Right, so it could have been 600k ifthere there was a second agreement between
whoever negotiated with the hospital.
Absolutely.
You're saying is in the absence of that,like if there is no contractually agreed
upon number that was repriced in thereor there's no line item for something,
(23:16):
then CMS guidelines our enforce.
Yes.
For example, we were able to geta hold of a contract and they
got to pay 29,000 for robotics.
Well, robotics is not legallybillable, but it's in the
contract, so, the 29,000 stands.
One of the things that does becomeclear is that there are incentives that
carriers have, which may not always bealigned with their commercial customers,
(23:43):
and this almost seems like another oneof them where if the carriers trying
to figure out how to get leverage tohave a lower Medicare Advantage rate
similarly to how they may do someof the stuff that we talked about
in the show with Dr. Eric Bricker.
They also could do this like,all right, well, we're gonna add
another line item for robotics.
We're gonna add another line item.
(24:04):
So things that they were notpreviously able to charge for it's
like the carrier can be like, allright, well, we'll do this for you.
Now all of a sudden, the hospital canincrease their charges for things in
ways that don't necessarily show up.
And I'm, I'm saying this a littleblindly, and if anybody knows the
right answer, certainly let me know.
But that's not gonna impacttheir, you know, their net net
(24:26):
percent over Medicare, right?
Like they could still say, oh,we're 200% of Medicare overall, or
whatever it is, because now they'recharging for things that they
previously weren't able to charge for.
But maybe it's not 200% of Medicare.
It should have been zero.
It's very complex.
When we review claims, we see innetwork 30% of ineligible charges,
(24:48):
and that's after the discount.
Out of network we find 70% and above.
And, so that is a significant amountof overspend in claims and that
just trickles down to increasingyour premiums, everything that
would go within a self-insured plan.
So what's your advice for, for hospitals?
We've got lots of hospitals whowould love to direct contract
(25:09):
or work with plan sponsors.
How do they get theirbilling up to the task?
Because, you'd think that any plansponsor, savvy enough to direct contract,
would also be savvy enough to have paymentintegrity review, and if it's Armageddon
every time the plan needs to correct awrong bill, that's not gonna be great
for client relations or client retention.
(25:31):
So what, what do you think hospitalsneed to know about all of this?
Let's, let's designate apoint of contact for review.
Let's assign someone that's knowledgeableenough in compliance and billing to lead
you and coordinate you directly to whereyou can go get those itemized statements.
Then let's provide completedocumentation without delay.
Let's provide the itemized statement,the UB-04, the medical records.
(25:53):
Let's be proactive aboutproviding those when asked for not
continuing to prolong the process.
Let's respond to the auditfindings with openness.
Let's, let's, when discrepanciesare identified, nobody's
trying to point fingers.
We just wanna clean thebill so it can be paid.
So let's keep an open mind with itand, work with the company, review
(26:15):
company that is reviewing the claims.
And then I would just wish they wouldrespect the legal rights of ERISA plans
and the vendors to conduct audits and notuse legal threats towards anyone that is
trying to do the right thing to reviewthe statements, to review the claims in
order to fulfill their fiduciary duty.
(26:36):
So hopefully our findings would be qualityimprovement opportunity for hospitals.
There's a lot of hospital executivesthat listen and it sounds like what
you're saying is, I mean, it soundsreasonable to me, first of all, have a
designated point of contact who knowswho has been trained, which also could
eliminate the last thing that yousaid is like, don't threaten things,
(26:57):
which are not based on the law, right?
Then the second thing is when askedprovide the documents, they're
supposed to provide the documents,so provide them, respond quickly.
I mean, this just seems likeyour average, normal customer
service kind of stuff here.
And then as you said, respectthe legal right of vendors.
(27:18):
But you know, if hospitals wouldlook at it this way, when their
compliance teams lean into accuracyand partnership, everyone wins.
It strengthens trust withpayers and ensures patients and
plans are only charged for whatthey actually need to pay for.
And I think right now in healthcare,strengthening that trust is so important.
Yeah.
(27:38):
We just, we just literally did a showabout the amount of distrust in the system
and how just the number, it's over half ofpatients are scared to go to the hospital.
They're delaying care because they'reso worried that their bill is gonna
bankrupt them or their family.
You want the hospital to be paid.
I'm all for the hospitalbeing paid correctly and the
(28:01):
plan paying what they owe.
But when you start billing for things andnegotiating secret contracts with carriers
that involve charges that are not legallybillable, that's where I have a problem.
So what you're trying to do is go backthen and say, look, I know you and the
carrier cooked up a charge where you'reallowed to charge for robotics, but you
shouldn't be charging for robotics, sowe're not gonna pay you for robotics.
(28:25):
And they're coming back and saying, yeah,but I got a deal to charge for robotics.
Like I got paper on that.
Therefore, we are gonnacharge for robotics.
Like that's when things get dicey.
Exactly.
Typically, you wouldn't mess with carrierrates, but if it's a charge that's not
supposed to be billable, you shouldn'tnegotiate a rate and to charge it.
So we have a few pieces of advice forhospital executives and finance teams
(28:49):
that we just went through, mainly focusedon assign a point of contact to work
with plan sponsors or their vendorson billing questions and this point
of contact should know the applicablelaws and is customer service oriented.
Now we've pivoted into advice for plansponsors, or I'm going to pivot us there,
but with some amount of trepidationbecause I was gonna say, oh, first piece
(29:14):
of advice is to make sure that your TPAor ASO or health plan isn't doing things
where they get a better Medicare Advantagerate by agreeing that their commercial
clients can get charged for stuff thatCMS says you shouldn't get charged for.
But now I'm hesitant because giventhat these are secret deals between
the carrier and the hospital, I am notsure how you would even know that the
(29:39):
carrier health plan has negotiated withthe hospital and included things that
shouldn't be charged for until the plansponsor got a bill for it, unless it's
somehow, I don't know, somewhere in thecarrier RFP, you say something like,
here's a stipulation of this contract.
All charges excluded byCMS will remain excluded.
(30:01):
Like you actually put that inthe RFP as a contract term.
I would think so.
I'm not real certain how that works, butI do know that as a plan sponsor, you
should, you have a right to the contractsone, and you should, before you sign,
look over your plan, detail your plandocuments, and add in amendments or add
(30:21):
in additions that say, we will not payfor charges that are not legally billable.
As a plan sponsor, you stick a line inthere that say, if you're not allowed to
charge for it, we're not paying for it.
We just not bill those things thataren't legally billable, and then
no one will have a problem with it.
So it would be really nice if thatwe could all come into compliance
(30:41):
with what's legal and what's not.
Okay.
So we talked about a couple ofdifferent things to do proactively here.
Is there, is there anything else?
I would assert your legalrights as a plan sponsor.
You have the right to reviewitemized statement UP-04.
You have the right to conduct pre and postpayment reviews, and you have access to
provider contracts with the no gag clause.
(31:02):
And then I would also partnerwith an independent review firm.
If you get, if a plan tells you ora carrier tells you that they are
reviewing your bills and they alreadyhave someone in house that's reviewing
them for you, I would say I wannabring in my own independent third party
that doesn't have skin in the game.
Recapping there, assert rights.
Every plan sponsor has the right to reviewcharges to review the itemized bill.
(31:28):
Also access to the provider contractsvis-a-vis the no gag clauses.
These things should be available.
And then lastly, based on thisconversation, I don't think there
should be any question that itshould be an indie bill reviewer.
Kimberly Carleson, thank you so much forbeing on Relentless Health Value today.
Thank you for having me.
Hi, this is Tom Nash, oneof the RHV team members.
(31:50):
You might recognize my voicefrom the podcast intro.
If you love the show and you wannashow us your support, please follow
us on your favorite podcast app.
Sign up for the newsletter,or maybe consider making a
small donation in the tip jar.
Thanks so much for listening.
Episode 480.
" Payment Integrity Meets HealthSystem Boasts, Such as Our Rates
Are 2x Medicare, and CarriersWho Also Have Medicare Advantage
Contracts." Today I speak with Kimberly
Carleson.
(00:24):
American Healthcare Entrepreneurs andExecutives, You Want to Know, Talking.
Relentlessly Seeking Value.
You know that episode from this springwith Eric Bricker about stop-loss
provisions as a way for some hospitalsso inclined to make more money without
technically at least raising rates likethey can substantially increase the
(00:46):
overall revenue from plan sponsors,the ones not paying attention at
least, while still able to claim theyare net net 0% increase or are very
much still 2x Medicare, for example.
Well, today we stumble on a few morestrategies to do the same thing in
the show today with Kimberly Carleson.
So spoiler alert.
(01:07):
Now look, all this matters.
It big time matters.
Anything that has to do with healthsystems and their billing of plan
sponsors matters because as we haveheard from multiple guests multiple
times, the shows with Shawn Gremminger,Cora Opsahl, Claire Brockbank,
Marilyn Bartlett, to name a few.
We have heard over and over againthat usually almost 50% of plan
(01:29):
sponsor costs have something to dowith members going into the hospital
and or getting care somewhere thatis under a hospital's umbrella.
50%.
And today we learn that up to80% of hospital bills may contain
some error with 25 to 30% ofthose errors being significant.
I just asked AI and it said thatapproximately five to 10% of total
(01:53):
hospital spend by plan sponsorsmight be attributable to billing
inaccuracies or excessive charges.
My guest today, as I have mentionedtwice already, Kimberly Carleson also
mentions a few stats about just themagnitude of some of these mistakes.
I mean, five to 10% of 50% oftotal spend, is a lot of money.
Okay, so let's discuss what we discusstoday, Kimberly Carleson and I. We start
(02:16):
out kind of digging into the where, why,and how many of these errors come to be.
Then we talk about some advice forthose who work at health systems
who may be interested for real inredressing some of the stuff that we
discuss and this whole conversation.
And also Kimberly's advice for healthsystem leaders is particularly relevant
for anybody looking to do directcontracting with plan sponsors, of course.
(02:39):
Because yeah, with a carrier in themiddle of some of this stuff, it might
not be entirely clear to many plansponsors, the magnitude or the member
impact of these billing mistakes.
However, in a direct contract,yeah, expect eyes on, so it
certainly would make good sense toget ahead of some of this stuff.
As I don't know, I know nothing really,but after talking to Kimberly and after
(03:01):
talking with Dawn Cornelis a few yearsago, for sure, some of this stuff can
be chalked off to weird complexitiesand not repeatable kinds of excusable
mistakes, but a good deal of it kindof seems like, how shall I say this?
Preventable.
It seems to fall into a categoryof why is this happening and
it's pretty darn obvious it's aproblem, and yet it still persists.
(03:22):
Where this conversation heads nextis getting into advice for plan
sponsors, which I will summarize foryour convenience right now, and maybe
add a couple of supplementary points.
Advice for plan sponsors that comes up inthis conversation with Kimberly Carleson,
number one, and this is a biggie,have a third party audit of claims.
(03:42):
The point comes out pretty clearlyin this show, but in that earlier
episode I mentioned the onewith Dawn Cornelis it also, this
point comes out just as strongly.
And right now in the timespace continuumin 2025, I don't know how you could
even argue with it, get a third partyto audit your claims, who isn't owned
by the same company as your ASO or TPAor whoever is processing the claims.
(04:04):
Julie Selesnick was on the pod lastspring and in that episode she says,
Look, it is the very definition ofa conflict of interest if you as a
fiduciary hire somebody and expectthem to accurately audit themselves.
On this exact same topic in that recentTake Two episode with Justin Leader
about The Mystery of the Weekly ClaimsWire, he talks about an example where
(04:26):
a TPA was using a branch of their owncompany to audit basically their own
claims, and they found $21,000 in errors.
This wasn't even enough to cover thefee for finding those errors, which
in this case was $25,000, right?
They spent $25,000 to find $21,000 total. Meanwhile, the employer, they then got
(04:47):
a third party in the mix who found allthe actual errors, and it summed up to
20 times that the third party auditorfound over $400,000 in errors that they
then recouped for the plan sponsor.
So yeah, first piece ofadvice for plan sponsors.
Don't do that.
Get a different payment integrity vendor.
You need somebody else toaudit claims other than the
(05:08):
person who is doing the claims.
Second piece of advice that comes upin the conversation that follows with
Kimberly Carleson, I'm just gonna giveyou the advice, but you need to listen to
the show to get the real full gist of it.
Contract amendments that the TPAor ASO or health plan that they
cannot negotiate to pay for chargesthat are not legally billable.
(05:31):
Right.
And this one is interesting for morethan just payment integrity purposes.
I'd say it's also interesting for directcontracting purposes and for TPA RFPs.
Again, Kimberly and I talk about thisat some length, and the whole thing
just reminded me of something that Ihad seen Dr. Cristin Dickerson write,
she wrote, "It is not just aboutwhat percentage of Medicare is paid.
(05:56):
It's about the codes charged.
While an imaging center may chargeone or two codes for an exam, I
see hospitals charging eight codes.
Those eight codes even paid at200% of Medicare are ridiculous."
This is just also, if you startthinking about it, why you gotta
watch it with those RBP contracts.
And, Dr. Dickerson gives a really goodexample of even if you have an expert who
(06:20):
limits code payments to some agreed uponamount, there are many cases where that
just doesn't work and hospital billingsystems are able to bypass the controls.
Now, what I just said is a little wonky.
If you didn't understand it, dolisten to the pod and then come back
and you will totally understand it.
But yeah, bottom line, don't accidentallyagree to pay for stuff that should
(06:44):
be free or shouldn't be billed forin the first place as per the law.
That is piece of advice two that comesup in the conversation that follows.
And then piece of advice three isknow your rights as a plan sponsor.
There is the CAA, theConsolidated Appropriations Act.
There is the no gag clauses rules.
Plan sponsors have an absolute rightto the itemized bill and they don't
(07:08):
have to pay until they get one.
And it is deemed clean.
Plan sponsors have a rightto the hospital contracts.
The TPA/ASO/health plan has negotiated.
And look, having a right and actuallygetting those rates which some deem a
trade secret are two different things.
So it is increasingly up to the plansponsor to run a clean RFP, request
(07:29):
for proposal, using best practiceslike Claire Brockbank talked about
in that episode from last fall.
If an RFP bidder clearly admits theydon't have transparent business processes,
or they have all kinds of trade secretsthat impede your access to transparent
information, and if they don't seemto be so inclined to change, then
it's on us really to exclude them fromthe RFP if they don't meet the terms.
(07:53):
Ann Lewandowski talked about this alittle bit in the whistleblower episode
from a few months ago, just how theDepartment of Labor definitely excuses
ERISA plans during a contract period whoare using a vendor who it turns out is not
doing things as per ERISA requirements.
But that leeway ends at contract renewal.
(08:16):
My guest today as aforementionedis Kimberly Carleson.
She is the CEO of US Beacon, wherethe mission is to meticulously
review and optimize medical bills.
My name is Stacey Richter.
This podcast is sponsoredby Aventria Health Group.
Kimberly Carleson, welcometo Relentless Health Value.
It's a pleasure being here.
Thank you for having me.
What's the magnitude of the issues here?
(08:39):
You, you know, just obviously forthe members themselves, this can
be a catastrophic situation, butif I'm thinking about this from
the standpoint of the plan sponsor,what can you tell me about, you
know, if I said, eh, is it worth it?
What would you say?
For an example, in a review from oneclient we have, there was 55,000 members.
(08:59):
There's a $600 million medical spend.
We had identified 64 millionin excessive charges.
That's more than 10% of thetotal spend, and that was
just claims $10,000 and above.
A lot of us sit in chairs and it's justlike a million here, but $64 million.
(09:19):
That's a lot of money.
A lot of money.
And that was in one year?
One year.
Mm-hmm.
So, what are the most prominent ways thata health system, a hospital, may wind
up messing up a bill and overcharging?
So I think you havedocumentation, delays or gaps.
Physicians and clinicians may, theywork under tight constraints, so
(09:42):
documentation is delayed or incomplete.
Billing teams may make assumptions orapply standard charge protocols that don't
reflect what actually occurred, and thenyou've got, um, your manual data injuries
or your fat fingers that accidentallyhit a button that they didn't mean to.
It pulls the wrong code altogether,and so you're charged extra.
(10:03):
You've got unbundling services wheresome procedures may be billed in a
bundled charge, and then on the itemizedstatement, they're billed separately.
They pull out every singlecharge from that bundled charge.
You have upcoding.
Codes are sometimes assigned to ahigher level of complexity then what's
medically necessary or documented?
There's duplicate billing chargingfor, uh, non FDA approved items.
(10:25):
We had a pacemaker one time thatwas non FDA approved, and you can't
charge for that under CMS guidelines.
And then you've got inflated markupson routine items, time-based charges
without time documentations like inORs or recovery room, sometimes billing
services that weren't even rendered.
And then I think you have the lack ofcoordination between departments because
(10:45):
there's such a demand and the hospitalsystems are so packed and understaffed
that there's lack of coordination.
You have misuse of revenue codes,emergency room coding, details
that are not properly done, andthen repetitive charges on multiple
days that they're in the hospital.
So just kind of summing up whatyou, you said there, it sounds like.
(11:07):
I think my big takeaway from everythingyou just said is that it could be one of
many ways that, that this could happen.
I mean, it could.
That's just a few.
Yeah.
Yeah.
It was a pretty, prettycomprehensive list.
If that was just a couple of'em, um, I'm getting the drift.
Hi, I am Keith Passwater,CEO of Havarti Risk.
As a healthcare actuary, I cansometimes get deep into the weeds
(11:27):
of the math behind healthcare.
Maybe you experience that aswell, getting hyper-focused
to your corner of healthcare.
That's why I so appreciateRelentless Health Value.
Listen to the conversations reminds methat our healthcare system is huge, but
we're ultimately here for the patients.
If you wanna make a difference inhealthcare, don't miss an episode
of Relentless Health Value, and Ireally encourage you to follow the
podcast on Apple Podcast or Spotify.
(11:49):
And please leave a review.
Thanks for listening.
So, as you said, it could be just simplyfat fingers, just somebody messed up.
It could be, it sounds like a failureto communicate adequately, maybe
between like the clinical team andthe billing team, so somebody makes
an assumption that was not correct.
(12:11):
The bundling errors we had Dawn Cornelison several years ago, and this is one
of the things that she talked about alot, where, you know, if you're charging
a bundled price, you can't then go backand charge for the individual services
that are part of that bundle also.
You can just have duplicate billing,be it just a duplicate billing.
Or it could be if a, if it's an inpatientwho's in the hospital for multiple
(12:32):
days, they wind up charging for thesame thing multiple days in a row.
That should be one, as you said,time-based billing, you know, something
was for like in an OR whatever, andthat was not necessarily documented
or is inaccurate in some way.
I mean, I really don'tthink it's intentional.
I think it's just sometimes I don't.
Most of the time, I don't thinkit is, but it's just a lack of
coordination between departments andjust in a, everyone's in a hurry.
(12:56):
Hospitals are large, really complicatedentities with lots of stuff going
on and lots of different people.
And two, they change systems so much.
And then I'm sure also from theclinical side, like as a clinician,
you might not even realize what'sbeing done with what you're typing in.
Like you're trying to document whathappened in the clinical visit and
somebody else is gonna take thatinformation and do other things with
(13:19):
it, that now it's outside of yourpurview, what winds up happening
down that particular vector stream.
But before, before we get, I definitelywanna ask you for some representative
examples, maybe of all of this comingtogether in a way that is worthy
of talking about on this podcast.
But before we get there, let,let me ask you something.
(13:42):
How do you know this?
Like, are you actually talkingto members and they say, no,
I didn't have that in the ER.
Like, or whatever you know.
Well, the coding guidelines, Imean, if you know your coding and
you've been doing it long enough,you're aware of what can be charged.
You're aware of someone goesinto the ER for a stitch because
(14:05):
they fell and bumped their head.
They're not a level four ER visit.
They're a One or two, you know,so you know from the medical
records that this charge cannotbe escalated up to a level four.
So you just read the records.
So it's not just, you know, theyalways say, you know, absolutely
go and get an itemized bill.
Like we've had Marshall Allen on the,like, you can practically talk to no
(14:28):
one who won't tell you that the firstthing that to do here with any sort
of billing conundrum of almost anykind is to go get that itemized bill.
So can you just look at that itemizedbill and see that what the severity
is, or make some assumptions there?
I mean, some of the stuff that youwere talking about, definitely,
like if it's a duplicate charge orwhatever, if you get the itemized
(14:50):
bill, you would be able to tell.
But some of the stuff relative to theseverity of it, like wouldn't they just
code that it was a level four trauma andnot write down that it was one stitch.
Right?
You can absolutely see itfrom the itemized bill.
The itemized bill's gonna tell you ifthey had Tylenol or if they had codeine.
You know, it's going to tell you andyou're gonna be able to see exactly
what that patient went through atthe time they were in the hospital.
(15:13):
Let me just ask you for a couple ofdifferent examples here, and one of the
reasons why I'm for sure digging in onthis is just because we talk a lot on
this podcast about how much plan sponsorstend to spend on hospital charges.
You gave an example of a plan sponsorwhere almost 10% of charges were
(15:36):
inaccurate and could be recouped.
So because the dollars areso big, errors can be huge.
Can you just maybe run through justsome real world examples of a situation
that happened, just which may givelisteners a little bit of context here.
We had a lung transplant and it wasout of network, but it was a single
case agreement and it was 1.5 millionwas how much they were charging.
(16:00):
We were reviewing it and theycharged $676,000 for the organ.
You can't charge that for the organ.
You have to charge 56,000.
That's all, that is allowed by law.
So once we got done with that bill,it went from 1.5 million to 290,000,
and that's just ineligible charges.
We just eliminate whatlegally should not be there.
(16:23):
From CMS guidelines, NCCI edits, NUBC,AMA, Social Security Act, all of those
go into play with what we look at andit's just what legally is not owed.
So someone was trying to charge$600,000 less for something that they
should have charged 50 something.
So it's like 10, 12times what was allowable.
(16:44):
Yes.
So it's easy to see how these chargescan just add up and it's, it was
probably like their charge, mastercharge or whatever, and it almost
sounds like the re-pricer like failedto notice this or whatever happened.
But that bill made it all the waythrough the gauntlet and it was
ready to be paid or already paid.
I've seen implants be up to $30,000when they should have cost 6,000.
(17:08):
IV hydration therapy.
That is a big one.
You can't charge for saline in an IVthat goes within the hospital charge.
Operating room charges.
I even saw the other daycutting a pill, a pill cutter.
They charge like $20.
That's just slicing the pill in half.
Your recovery room charges, theydon't document the hours, so that
(17:30):
can be extremely overcharged.
Respiratory therapy services, if they'rebilled daily, it often lacks medical
necessity or for provider information.
You've got, oh, venina puncture whenthey put a needle into your arm.
They can't charge you for the push ofthe needle, and they do that a lot.
Uh, the EKGs are well known for duplicatebilling and charging excessively when they
(17:53):
should be within the bundled code itself.
Sterilization, I've seen it 19 times ona bill separated out, but sterilization
is bundled in a code within the surgery.
So that should never be separated.
Over the counter medication,that's not billable.
It's not legally billable.
You can't charge for Tylenol.
Implant components.
That's a huge one.
(18:14):
They're all bundled into a code.
You can't charge for each screw.
Again, as we all know, and I thinkyour examples indicate why it's so
important to get the itemized bill
Absolutely every time.
You have to go back and askfor the itemized and sometimes
they don't send it then.
You have to, it's verydifficult to get at times.
As a plan sponsor, do I have alegal right to get the itemized
(18:36):
bill or how does this work?
Absolutely.
You have a legal right under ERISA,the Consolidate Appropriations Act.
You have a right to review your documents,itemized statement UB-04 before it's paid.
But if they delay long enough, now all ofa sudden my member's getting nasty grams.
Like, how do you go about gettingwhat you need while, meanwhile
(18:56):
there's all this other, you know, I,I don't think the process probably
stopped that the, the hospital just'cause this is going on on the side.
Legally by law allowed to have a reviewof your claim and you want a clean...
Once you turn in a clean claim, thenthe 30 days for payment can go, the
clock can start ticking for payment.
We hound them with fax, emails,calling them in order to
(19:19):
get that itemized statement.
Most of the time a lot ofhospitals are compliant.
Most are, we know the ones that aren't.
So how the process typicallyworks is the plan sponsor is gonna
go ask for the itemized bill.
They may turn around and send yousomething else, like there's this UB-04
that gets brought up sometimes AutumnYongchu talked about this just kind of
(19:40):
general idea where there's itemized billsand then there's other documents that
at the end of the day still are roll-upsthat the hospital may respond with, which
actually do not give enough informationif you're trying to do a bill review.
So then you gotta turn aroundand say, no, no, no, no, no.
I want the actual itemized bill.
And you can cite theprecedents for getting it.
(20:00):
Do they have like a a period of timethat they must send the itemized bill
over in, or do you just say, you know, weain't gonna pay it until you get me the
itemized bill and therefore it's on themto choose how long they're gonna delay.
Each state is different.
We state those laws and we state howmany days they have and the date.
Usually you would have theallowable amounts, send it
(20:21):
back, and that's what you pay.
And typically, very few appealswhen you do it right, when you,
what's legally owed is paid.
So if a plan sponsor is up on theregs and, and knows how much, what,
you know, what the actual contractualallowable amounts are and a health
system is told, look, this is the drill.
This is what thesecharges should have been.
(20:43):
Then they're not like in the meantimefighting with you while they're sending
the member collection notices about thehigher amount or something like that.
Right.
And so most don't allow that.
As a bill re reviewer, youlet 'em know how, why you have
did not allow those charges.
Give them the chapter number, give 'emthe page number, whatever you have to do.
I just got one the other day and Ihave to send back the chapter number
(21:05):
of CMS guidelines, the page numberof why this cannot be charged.
But if you're a plan sponsor, what?
What does CMS have to do with this?
Those are the guidelines for billing.
The CMS guidelines is whatyou go off of the CPT codes.
Mm-hmm.
From the CMS, AMA, NCCI, all ofthose go into how much you're
legally and contractually owe.
Even as an ERISA plan?
(21:26):
Yes, even as an ERISA plan.
You cannot add the CPT code withanother CPT code that is supposed
to be all in the bundled CPT code.
Do you understand?
You can't break certain CPT codesout if they're bundled into one.
These are CMS regs.
Like if you're charging a bundlepayment, you can't just turn around
and charge all the things that areactually part of the bundle also.
(21:47):
There are other things, like you can'tcharge for sterilization multiple times.
You can't charge for pill splitting, youcan't charge for venipuncture, right?
Like these are all sort of part andparcel to what constitutes a code.
There's federal guidelines for coding.
Well, it's just interesting to methat some things do have those caps
on them, like 60k for an organ.
(22:07):
Well, and you know too, if anetwork has a contracted rate or a
negotiated rate, there's nothing youcan do about what is being charged.
If their contract says that theycan charge for robotics, then
they can charge for robotics.
And you're not really allowed tocharge for robotics because that's
integral to the hospital equipment.
Billing can be so confusing, and I canunderstand how hospitals are perplexed
(22:30):
when getting them out or making mistakesbecause it is very confusing and depending
on the provider and plan you have.
Also, are you saying that the lungtransplant that wound up costing,
you know, they were charging600,000 for a lung when it should
have been 50,000 for the lung.
Are you saying that sometimes, thecarrier, whoever, there's another
(22:52):
contract that would overridethat, those CMS guidelines.
Right, so it could have been 600k ifthere there was a second agreement between
whoever negotiated with the hospital.
Absolutely.
You're saying is in the absence of that,like if there is no contractually agreed
upon number that was repriced in thereor there's no line item for something,
(23:16):
then CMS guidelines our enforce.
Yes.
For example, we were able to geta hold of a contract and they
got to pay 29,000 for robotics.
Well, robotics is not legallybillable, but it's in the
contract, so, the 29,000 stands.
One of the things that does becomeclear is that there are incentives that
carriers have, which may not always bealigned with their commercial customers,
(23:43):
and this almost seems like another oneof them where if the carriers trying
to figure out how to get leverage tohave a lower Medicare Advantage rate
similarly to how they may do someof the stuff that we talked about
in the show with Dr. Eric Bricker.
They also could do this like,all right, well, we're gonna add
another line item for robotics.
We're gonna add another line item.
(24:04):
So things that they were notpreviously able to charge for it's
like the carrier can be like, allright, well, we'll do this for you.
Now all of a sudden, the hospital canincrease their charges for things in
ways that don't necessarily show up.
And I'm, I'm saying this a littleblindly, and if anybody knows the
right answer, certainly let me know.
But that's not gonna impacttheir, you know, their net net
(24:26):
percent over Medicare, right?
Like they could still say, oh,we're 200% of Medicare overall, or
whatever it is, because now they'recharging for things that they
previously weren't able to charge for.
But maybe it's not 200% of Medicare.
It should have been zero.
It's very complex.
When we review claims, we see innetwork 30% of ineligible charges,
(24:48):
and that's after the discount.
Out of network we find 70% and above.
And, so that is a significant amountof overspend in claims and that
just trickles down to increasingyour premiums, everything that
would go within a self-insured plan.
So what's your advice for, for hospitals?
We've got lots of hospitals whowould love to direct contract
(25:09):
or work with plan sponsors.
How do they get theirbilling up to the task?
Because, you'd think that any plansponsor, savvy enough to direct contract,
would also be savvy enough to have paymentintegrity review, and if it's Armageddon
every time the plan needs to correct awrong bill, that's not gonna be great
for client relations or client retention.
(25:31):
So what, what do you think hospitalsneed to know about all of this?
Let's, let's designate apoint of contact for review.
Let's assign someone that's knowledgeableenough in compliance and billing to lead
you and coordinate you directly to whereyou can go get those itemized statements.
Then let's provide completedocumentation without delay.
Let's provide the itemized statement,the UB-04, the medical records.
(25:53):
Let's be proactive aboutproviding those when asked for not
continuing to prolong the process.
Let's respond to the auditfindings with openness.
Let's, let's, when discrepanciesare identified, nobody's
trying to point fingers.
We just wanna clean thebill so it can be paid.
So let's keep an open mind with itand, work with the company, review
(26:15):
company that is reviewing the claims.
And then I would just wish they wouldrespect the legal rights of ERISA plans
and the vendors to conduct audits and notuse legal threats towards anyone that is
trying to do the right thing to reviewthe statements, to review the claims in
order to fulfill their fiduciary duty.
(26:36):
So hopefully our findings would be qualityimprovement opportunity for hospitals.
There's a lot of hospital executivesthat listen and it sounds like what
you're saying is, I mean, it soundsreasonable to me, first of all, have a
designated point of contact who knowswho has been trained, which also could
eliminate the last thing that yousaid is like, don't threaten things,
(26:57):
which are not based on the law, right?
Then the second thing is when askedprovide the documents, they're
supposed to provide the documents,so provide them, respond quickly.
I mean, this just seems likeyour average, normal customer
service kind of stuff here.
And then as you said, respectthe legal right of vendors.
(27:18):
But you know, if hospitals wouldlook at it this way, when their
compliance teams lean into accuracyand partnership, everyone wins.
It strengthens trust withpayers and ensures patients and
plans are only charged for whatthey actually need to pay for.
And I think right now in healthcare,strengthening that trust is so important.
Yeah.
(27:38):
We just, we just literally did a showabout the amount of distrust in the system
and how just the number, it's over half ofpatients are scared to go to the hospital.
They're delaying care because they'reso worried that their bill is gonna
bankrupt them or their family.
You want the hospital to be paid.
I'm all for the hospitalbeing paid correctly and the
(28:01):
plan paying what they owe.
But when you start billing for things andnegotiating secret contracts with carriers
that involve charges that are not legallybillable, that's where I have a problem.
So what you're trying to do is go backthen and say, look, I know you and the
carrier cooked up a charge where you'reallowed to charge for robotics, but you
shouldn't be charging for robotics, sowe're not gonna pay you for robotics.
(28:25):
And they're coming back and saying, yeah,but I got a deal to charge for robotics.
Like I got paper on that.
Therefore, we are gonnacharge for robotics.
Like that's when things get dicey.
Exactly.
Typically, you wouldn't mess with carrierrates, but if it's a charge that's not
supposed to be billable, you shouldn'tnegotiate a rate and to charge it.
So we have a few pieces of advice forhospital executives and finance teams
(28:49):
that we just went through, mainly focusedon assign a point of contact to work
with plan sponsors or their vendorson billing questions and this point
of contact should know the applicablelaws and is customer service oriented.
Now we've pivoted into advice for plansponsors, or I'm going to pivot us there,
but with some amount of trepidationbecause I was gonna say, oh, first piece
(29:14):
of advice is to make sure that your TPAor ASO or health plan isn't doing things
where they get a better Medicare Advantagerate by agreeing that their commercial
clients can get charged for stuff thatCMS says you shouldn't get charged for.
But now I'm hesitant because giventhat these are secret deals between
the carrier and the hospital, I am notsure how you would even know that the
(29:39):
carrier health plan has negotiated withthe hospital and included things that
shouldn't be charged for until the plansponsor got a bill for it, unless it's
somehow, I don't know, somewhere in thecarrier RFP, you say something like,
here's a stipulation of this contract.
All charges excluded byCMS will remain excluded.
(30:01):
Like you actually put that inthe RFP as a contract term.
I would think so.
I'm not real certain how that works, butI do know that as a plan sponsor, you
should, you have a right to the contractsone, and you should, before you sign,
look over your plan, detail your plandocuments, and add in amendments or add
(30:21):
in additions that say, we will not payfor charges that are not legally billable.
As a plan sponsor, you stick a line inthere that say, if you're not allowed to
charge for it, we're not paying for it.
We just not bill those things thataren't legally billable, and then
no one will have a problem with it.
So it would be really nice if thatwe could all come into compliance
(30:41):
with what's legal and what's not.
Okay.
So we talked about a couple ofdifferent things to do proactively here.
Is there, is there anything else?
I would assert your legalrights as a plan sponsor.
You have the right to reviewitemized statement UP-04.
You have the right to conduct pre and postpayment reviews, and you have access to
provider contracts with the no gag clause.
(31:02):
And then I would also partnerwith an independent review firm.
If you get, if a plan tells you ora carrier tells you that they are
reviewing your bills and they alreadyhave someone in house that's reviewing
them for you, I would say I wannabring in my own independent third party
that doesn't have skin in the game.
Recapping there, assert rights.
Every plan sponsor has the right to reviewcharges to review the itemized bill.
(31:28):
Also access to the provider contractsvis-a-vis the no gag clauses.
These things should be available.
And then lastly, based on thisconversation, I don't think there
should be any question that itshould be an indie bill reviewer.
Kimberly Carleson, thank you so much forbeing on Relentless Health Value today.
Thank you for having me.
Hi, this is Tom Nash, oneof the RHV team members.
(31:50):
You might recognize my voicefrom the podcast intro.
If you love the show and you wannashow us your support, please follow
us on your favorite podcast app.
Sign up for the newsletter,or maybe consider making a
small donation in the tip jar.
Thanks so much for listening.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.