Articles

Methamphetamine (meth) is the number one killer in San Diego County among those using drugs, and a significant driver of violence in the community. Nationwide, meth is the fastest growing drug of abuse, representing over 798,000 annual emergency department (ED) visits, with deaths increasing 14-fold since 2015 (32,856 deaths in 2021 alone), yet no therapeutics are available. There is an urgent need for a safe rapidly acting antidote for methamphetamine.

With support from the National Institute on Drug Abuse (NIDA), Cambridge, MA-based Clear Scientific (www.clearsci.com) is developing an antidote for meth for use in the ED. This small molecule therapeutic, CS-1103, reverses meth intoxication by sequestering it in the plasma compartment and removing it from the central nervous system effect site. The now ‘inactive’ meth is eliminated from the body by filtration in the kidney. Rapid sequestration and clearance of meth reverses its effects. This mechanism of action is similar to Sugammadex (BRIDION®), a reversal agent for neuromuscular blockade. Unlike antibody-based treatments, CS-1103 not only binds harmful substances, but also rapidly removes them from the body – “Remove the Cause, Remove the EffectTM”. CS-1103 is formulated for intravenous injection for use in the ED.

In nonclinical studies, CS-1103 was highly effective in lowering the level of meth and rapidly reversing its toxic effects. CS-1103 has an excellent safety profile in Good Laboratory Practice (GLP) studies with rapid clearance and has been produced at scale under Current By Clear Scientific Good Manufacturing Practice (cGMP).

It is anticipated that the Phase 1 and 2/3 Clinical Trials will be completed in 2023 and 2024, respectively, with availability to ED physicians by late 2024.

For more information, please listen to the discussion between Dr. Roneet Lev and the Clear Scientific team on the High Truths podcast [Episode 91 September 19,2022].

IEPC is proud to present the 2022 Speaker Series! This free speaker series welcomes leaders in the field to cover timely and engaging topics that are important to independent emergency physicians. The sessions will precede each monthly conference call and are open to all IEPC members and those who may be interested in joining.

In May, IEPC welcomed Sheree Lowe from the California hospital Association to discuss updates and insights for the future.

This series is presented on the fourth Monday of the month January – November. Advance registration is required and can be completed by registering through the monthly email invitation. After registering, you will receive a confirmation email containing information about joining the meeting.

To view the full July 2022 newsletter click here.

Andrew Fenton, MD, FACEP was elected Chief of Staff at Queen of the Valley Medical Center serving nearly 400 medical staff members. Queen of the Valley is a full-service diagnostic and therapeutic hospital with 191 licensed acute care medical beds that employs over 1,200 people. Dr. Fenton is a partner of Napa Valley Emergency Medical Group which has provided acute care to the Napa community since 1974, and was one of the founding groups of IEPC.

To view the full July 2022 newsletter click here.

Presented by the Independent Emergency Physicians Consortium
Time & Date: 9:00AM – 9:30AM PT on the fourth Monday each month.

Membership in IEPC is not required to attend. Advance registration for the meeting is required. After registering, you will receive a confirmation email containing a link to join the call. This free speaker series welcomes leaders in the field to cover timely and engaging topics that are important to independent emergency physicians. The sessions will precede each monthly conference call and are open to all IEPC members and those who may be interested in joining

• July 25 – Andrew Young, MD, MPH, Medical Consultant, CA Dept. of Health Care Services to present Medi-Cal Update: State Initiatives to Improve Quality of Care
• August 22 – Peter Viccellio, MD, FACEP, Associate CMO, University Hospital to present Making Room for Patients – ED Turnaround Times
• September 19 – James Keaney, MD MPH FAAEM to discuss Institute for Justice in Emergency Medicine
• October 24 – Andrew Selesnick to discuss the Anthem Lawsuit
• November 28 – Laura Wooster, ACEP Associate Director, Public Affairs and Jeffrey Davis ACEP Director of Regulatory Affairs to share ACEP updates

Visit www.IEPC.org for more information

To view the full July 2022 newsletter click here.

By John Wallace, MD
President of IEPC

The No Surprises Act (NSA) was signed into law Dec. 27, 2020, by the President, as part of the $1.4 trillion Consolidated Appropriations Act, after years of negotiations. The surprise after NSA was passed was legal action against NSA as well as a surprise attack in cutting physician reimbursement.

When the NSA was passed, regulations were promulgated by the Department of Health and Human Services to implement the law, and which attempted to establish a Qualified Payment Amount (QPA) in stark contrast to the one established by the statute as passed by Congress. Six Lawsuits were filed against the Tri Departments of HHS, Labor and Treasury, the first filed by the Texas Medical Association and Dr. Adam Corley in Tyler Texas on October 28, 2021. They contended that the NSA interim rule was inconsistent with the law and that statutory provisions required that the Independent Dispute Resolution (IDR) “shall consider” additional factors for QPA other than “median in network rates” regarding payment decisions for physician services. The suit further contended that the QPA Presumptive Policy should be vacated, and that the Tri Departments violated the Administrative Procedure Act (APA) in issuing an interim final rule prematurely without a Notice of Proposed Rule Making (NPRM) with a 60-day comment period before issuing the final rule.

Similar contentions and lawsuits were filed by Air Ambulance Association, AMA and AHA filed suit in DC federal court. ACEP/ACR/ASA filed in Chicago Federal Court. Georgia ACEP and the Medical Association of Georgia filed in Atlanta Federal Court. A similar case was filed in New York Federal Court.

The positive verdict came out on February 23, 2022, at Texas Federal Court in favor of the Plaintiffs which vacated the September Interim Final Rule and returned the case back to the Tri Departments for corrections. CMS on 2/28/22 withdrew guidance documents based on the September rule that were invalidated by the Texas Federal Court.

In some states, health plans have cut physician payment rates by 20-30% to re-negotiate contracted rates. They set their own arbitrary payment rates.

ER Groups need to monitor health plans compliance with NSA and how Out Of Network (OON) payments compare with pre-NSA OON payments and submit 30-day notice of negotiation for cases that qualify for Federal Independent Dispute Resolution (IDR).

As of January 2023, the Health Plans must publicize in and out of network allowable rates, which will help minimize their unilateral and arbitrary payment of what they think emergency physicians are worth.

What can emergency doctors do to fight against pay cuts from the NSA? Data.

Data is power. Emergency physician hope to document the disparity between claims payment before and after NSA. Contact your billing company and request data for the QPA project. Here is sample language: “I am writing to authorize (fill in the name of the independent RCM or internal RCM function of the hospital) to produce and report (fill in group name) data and complete the spreadsheet for the QPA Reporting Project.” Since there is no PHI included, there is no need for secure transmittal. Send the completed survey templates with the name of your practice (Excel spreadsheets) to ACEP/ EDPMA consultant, Greg Hufstetler, at pahufs@comcast.net.

To view the full July 2022 newsletter click here.

By John Wallace, MD
President of IEPC

Anthem Health plan initiated a practice of “no pay” for ER diagnostic E and M code 99285 for discharged ER patients sometime in 2020. That the Health Plan’s new Dirty Trick, simply not pay anything. Ironically, while the health plans are committing fraud, they are accusing the doctors of fraud.

Anthem has referred Emergency Physician (EP) groups to their Special Investigations Unit and placed them under prepayment review to justify its behavior which is contrary to California Health and Safety Code Section 1371.35(a). California law requires health plans to pay the uncontested portion of each claim where emergency services have been rendered. Anthem argues they are not required to pay the claim, because of billing fraud, or alternatively that these are incomplete claims since there is a disagreement about the coding of the claim. However, a disagreement over coding, or even miscoding, does not constitute fraud or misrepresentation. Nor does including other services conducted in conjunction with a visit (eg. billing for an EKG read along with billing for the medical workup of a cardiac case), described as inappropriate unbundling, constitute fraud. The EP groups not coding to Anthem’s satisfaction is not fraud.

Similarly, a complete claim under 28 CCR § 1300.71 requires there to be sufficient information provided for the plan’s claims adjudicator to determine the plan’s liability. It contemplates that the physician will submit their information and the plan will independently determine their liability. In no way does it require that the physician code the claim to the satisfaction of the payer to be considered a “complete claim.”

The arguments made by Anthem that EP groups are submitting fraudulent or incomplete claims are preposterous.

Anthem appears to be targeting small independent EP groups vs large multi-hospital groups and including patients in coverage categories regulated by all: DOI, DMHC, ERISA and Medicare Advantage. Although, there is one large group that reported nonpayment by Medicare Advantage claims. The pattern of nonpayment is feared to be spreading from California small groups to a national trend and attack on emergency physicians.

While Anthem and Government regulators have met with impacted groups and California ACEP multiple times, the result has been extremely frustrating, and no payments have been issued for services already rendered. Legal recourse for OON Groups is available through litigation (see below case details) and multi-party lawsuit has been assembled. In network Groups are precluded by their contracts from litigating and instead must arbitrate. Anthem’s longstanding tactics to force ER Groups to accept low in network rates and efforts to avoid payment for ER services already rendered were chronicled in the March 2018 IEPC Newsletter: David vs Goliath: IEPC challenges Health Plan behemoth Anthem Blue Cross regarding unfair Provider contracting practices.

What can emergency doctors do? Groups can fight back against health plan dirty tricks by joining the lawsuit or submitting data to California ACEP. No all groups can afford litigation, but data sharing is essential in this fight.

Plaintiffs vs. BLUE CROSS OF CALIFORNIA, Case no: 22STCV05625
Legal Counsel: Buchalter and Associates
aselesnick@buchalter.com

Emergency Department Billing Data Collate all Level 5, 99285
discharged with zero pay from Anthem.
Submit to California ACEP executive director, Elena Lopez Gusman
elopez-gusman@californiaacep.org

Thanks to Elena Lopez Gusman, California ACEP Executive Director in assisting with the preparation of this article

To view the full July 2022 newsletter click here.