Tribunus Health’s Post

Effective January 1, 2025, the Florida DWC adopts updates to the Florida Workers' Compensation Health Care Provider Reimbursement Manual to include "convenience kits" as a "specialty service," and to adjust out-of-state provider reimbursement. Read more: https://bit.ly/3DASUhL #MyMatrixx #Statehousewatch

Reform of a rigged system is pretty much impossible. But people need to have some sort of coverage to ensure they can get medical care when necessary. Employers experience this also. Most people recieve their insurance coverage with partial or complete coverage reimbursed by their employer. Employers are key to restructuring this doom spiral of healthcare expense. And kicking health insurance providers out of the equation.

Dutch Rojas is exactly right! The high cost of healthcare and health insurance is no accident. The costs are high by design. They game has been rigged against us. The insurance carriers continue to post record profits quarter after quarter, while premiums and out-of-pocket amounts continue to grow making record numbers of Americans functionally uninsured. That's right, we continue to to struggle to afford the premiums and cost of healthcare while they continue to reap rewards of higher profits. So, do you continue playing a losing game? Or do you change the game, the rules, to benefit your company and your employees instead of the Big Health Insurance companies, healthcare systems, PBMs and Big Pharma? Yes, it is possible, and an advisor who aligns your best interests with theirs can show you how. If your current plan isn't working for you, what can it hurt to have a conversation with someone who can show you how to change the game?

🏥📊 In the healthcare industry, prior authorization is a critical cost-control mechanism that requires providers to secure approval from insurance companies before administering specific services. This process aims to prevent overutilization and ensure that treatments are medically necessary. 📝💼 However, it can also lead to service delays and claim denials if not managed properly. As healthcare professionals, how do we balance the need for cost control with timely patient care? Share your insights and experiences. #Medicare #Employeebenefits #Medicarecoverage #HRInnovation #HRChallenges #HR #DoctorsChoiceusa #Healthcare

★ Hospitals or clinics, along with healthcare practitioners such as doctors or nurses, comprise the group of covered entities that offer medical services, focusing on providing direct medical care to patients. Health plans are designed to provide coverage for various entities, including insurance companies like Medicaid, or for other means of accessing healthcare. In contrast, healthcare clearinghouses act as middlemen to convert non-standard health information into a standard format. ★ An external entity offering specialized assistance to a covered entity with access to PHI is a business associate. PHI handling on behalf of covered entities is often assisted by individuals or organizations known as business associates. Included in the definition of a business associate are billing organizations together with IT service suppliers along with businesses providing cloud-based data storage or transcription solutions #hospitals #compliance #clinics

Aetna vs. UnitedHealthcare Reimbursement Rates for Psychotherapy (60 min) In a sample of 33 hospitals, UnitedHealthcare reimburses Aetna at a higher rate for a 60-minute psychotherapy session. Take a look: - UnitedHealthcare: $446 - Aetna: $360 This disparity highlights the importance of comparing insurance providers. Higher reimbursement rates can significantly impact the financial sustainability of healthcare providers. Stay informed about competitive pricing and get in touch for your free trial today. #Healthcare #InsuranceRates #Aetna #UnitedHealthcare

In the ever changing world of healthcare reimbursement and patient care, it is easy as leaders to point a finger of blame. On May 1st, Modern Healthcare published an article on insurance companies CEO compensation for 2023. It was enlightening and provides another window into the delivery system of our US Healthcare system. In contrast, Becker’s Healthcare Review also compiled a list of the compensation for hospital CEOs. It is the classic example of a decades old argument of “When is enough, enough?” I’m not writing this to defend either position but to challenge us as healthcare leaders, whether payer or provider, to look in the mirror. What can we do as healthcare providers to change this trajectory? Repackaging the same fundamental arguments we’ve been arguing for years does nothing to change long-term outcomes. It’s a delay tactic. We need fundamental change, with the patient in mind. It’s not just talking points, advocacy, and rhetoric. It’s change backed up by data, empirical evidence (peer-reviewed), and innovation. Change is hard. Change requires work. Change requires strong leadership. Data will produce change. Transparency will produce change. A real look in the mirror without finger pointing is the first step towards that change. Healthcare providers need to be accountable, transparent, and keep the patient always at the center of any change. Healthcare payers need to be accountable, transparent, and keep the patient always at the center of any change. Drawing lines in the sand does not produce collaboration, innovation, and change. It cannot be an “us versus them.” The patient is harmed when we seek to prove a point versus getting uncomfortable and making a change. As George Bernard Shaw stated “Progress is impossible without change, and those who cannot change their minds cannot change anything.” #healthcare #uncomfortable #change #letsgetreal #healthcarereimbursement #revenuecycle #healthcarepayer #healthcareprovider

Great post from Dean Jargo last week regarding the abuses of UnitedHealth Group (https://lnkd.in/dGByAC57). The same behaviors that make United, and other BUCAH carriers incredible stocks will also make them the next Blockbuster.   Just like Blockbuster, these firms are middlemen that are abusive of their customers (remember those late fees?).   Over the next five years, these firms are about to be hit with a wave of lawsuits tied to profit-seeking abuses. Why do we know that? Because their customers are about to be hit by a wave of lawsuits tied to overpayments from poor claims adjudication or PBM abuses.   While that is happening, new innovative firms will be given an opening to disrupt. While they won't be perfect, here are the paths new firms will take to disrupt:   ✅ Removing High Deductibles: The math on high deductibles does not add up. Many studies have shown that HDHPs do not curb healthcare spend--they just change who pays. New health plans will find that they can offer the same costs to employers while removing HDHPs if they just cut out the waste that BUCA carriers added. Everyone wins, except for the current carriers.   ✅ Simple: The next generation will find new ways to make paying and identifying what coverage you have SIMPLE. There will always be some friction in what is covered, but we all know it can get SO MUCH BETTER.   ✅ Primary Care Focused: Direct primary care has proven itself dozens, if not hundreds of times over. It works. New plans will make this a cornerstone of their care, again saving employers while helping employees with powerful, connect convenience.   ✅ Protective: Remember when the Apple app store was revolutionary because apps in it were 'safe'--they would not kill your phone. Future healthcare will be similar. Not every provider will be included--only ones that are proven to be safe and high quality. Consumers will trade less choice for better safety. Again, by not including poor-quality providers, these new firms will be saving employers money. In healthcare, the most expensive care is the bad care.   So why has this not happened yet? These BUCAH carriers have over 800 billion in combined revenue. They have invaded every part of the ecosystem, sharing their wealth with brokers, employer plan sponsors and providers so that they can hold onto the status quo. I have worked in healthcare for 20 years and have seen it from both the hospital and employer side.   We are already seeing these firms' largest customer, Medicare, start to play hardball with them. Aetna told us last week that they are hurting.   While we all want the better healthcare, the disruption to healthcare will be enormous. Hospitals and providers will be paid differently. Employers will buy differently. Huge companies will go out of business.   Is your company ready for these coming changes?   #healthcarewaste #employeebenefits 

📉 Navigating the Math of Healthcare Reimbursement 🟰 An Unfair Equation? 📊 In today’s healthcare landscape, the math often doesn’t add up in favor of providers. With insurance reimbursement rates declining, denials on the rise, documentation and authorization requirements skyrocketing, the equation becomes increasingly complex. As we grapple with these challenges, it’s crucial to recognize how these factors compound to create an uphill battle against payer technology. Healthcare providers are caught in a relentless cycle where increasing paperwork and decreasing reimbursements create a disparity that is anything but fair. The question we need to address is: How do we balance the scales to ensure a system that supports both quality care and fair compensation? #Healthcare #Reimbursement #Documentation #HealthcareTechnology #HealthcareChallenges #FinancialManagement #Denials