The Most Important Story of This Year

By Chris Deacon on Linkedin

This may be one of the most important stories of this year, if not the most important. Not because it highlights one more way insurers and middlemen extract vast profits from the healthcare industry. Rather, it perfectly illustrates why trust in the system and its regulators is beyond broken.

In this made for real-life drama, Mr. Albright is a former CMS official who played a pivotal role in drafting post-ACA legislation about EFT transfers between carriers and providers. After leaving CMS, Mr. Albright joins Zelis where he capitalizes on his unique knowledge, overseeing revenue extraction from providers through EFT access fees—a questionable practice where providers were charged fees just to access the payments they were rightfully owed.

The plot thickens: CMS, recognizing the undue burden these fees placed on providers, issued a proposed rule aiming to outlaw such practices. But Mr. Albright won’t let his insider knowledge and influence go to waste. He contacts CMS officials, throws a temper tantrum fit for a child and resorts to legal threats to “encourage” them to retract the proposed rule. Stunningly (or not so stunningly if you’ve experienced the intersection of Government and healthcare) CMS did just that—with no public justification.

The outcome? Zelis and others like it remain unchecked, continuing to siphon substantial sums from providers, many of whom face severe financial strain in the face of massive industry consolidation and PE pressures.

I learned of this inappropriate extraction at the NJ State Health Plan, where the carrier forced OON providers to receive payment via pre-loaded debit cards that came with a hefty % fee. An OON surgical reimbursement could cost a physicians practice thousands of dollars ($100,000 x 3% = $3,000 in fees). Of course I lost this battle, but I tried to fight it. But I digress.

The point is, while collaboration between industry and regulators can foster innovation, it is clear that public interest is overshadowed by corporate gain when it comes to healthcare. This is but one example.