EP464: ER Visits Now 6% of Total Plan Spend. Is It Upcoding or What? With Al Lewis
02/20/25 • 31 min
Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction.
They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges.
If you want to understand the hidden forces behind escalating ER bills, this is a must-listen.
You can find the charts and links mentioned in the show notes in the link below.
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP464
✉️ 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
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
00:00 Introduction
08:32 What is going on in ER visits, and how big of a deal is the total spend?
10:16 Why is the price of ER visits going up when it should be going down?
11:59 What is the major source of unexpected medical debt?
13:27 What is code creep, and why is it happening?
16:26 Why are plan sponsors unable to negotiate emergency room services?
19:22 EP415 with Rob Andrews.
25:53 Why is it important not to agree to consent when you go in to visit the ER?
27:47 EP386 with Al Lewis.
31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees?
You can learn more at quizzify.com and by emailing [email protected]. You can also follow Al on LinkedIn.
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41),
Emergency room costs now make up 6% of total healthcare plan spending—why? In this episode, host Stacey Richter welcomes Al Lewis to break down the data behind rising ER expenses, separating fact from fiction.
They discuss whether increased patient acuity or widespread upcoding is driving costs, the impact of the No Surprises Act, and why plan sponsors struggle to negotiate fair ER rates. Plus, Al shares actionable strategies for employers to push back against inflated charges.
If you want to understand the hidden forces behind escalating ER bills, this is a must-listen.
You can find the charts and links mentioned in the show notes in the link below.
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP464
✉️ 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
📺 Subscribe to our YouTube channel https://www.youtube.com/@RelentlessHealthValue
🎤 Listen on Apple Podcasts https://podcasts.apple.com/us/podcast/feed/id892082003?ls=1
🎤 Listen on Spotify https://open.spotify.com/show/6UjgzI7bScDrWvZEk2f46b
=== CONNECT WITH THE RHV TEAM ===
✭ LinkedIn https://www.linkedin.com/company/relentless-health-value/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
00:00 Introduction
08:32 What is going on in ER visits, and how big of a deal is the total spend?
10:16 Why is the price of ER visits going up when it should be going down?
11:59 What is the major source of unexpected medical debt?
13:27 What is code creep, and why is it happening?
16:26 Why are plan sponsors unable to negotiate emergency room services?
19:22 EP415 with Rob Andrews.
25:53 Why is it important not to agree to consent when you go in to visit the ER?
27:47 EP386 with Al Lewis.
31:28 What steps can plan sponsors take to be proactive about limiting ER spending for their employees?
You can learn more at quizzify.com and by emailing [email protected]. You can also follow Al on LinkedIn.
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Betsy Seals, Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41),
Previous Episode
EP463: Medicare Advantage Policies—Which Will Stay and Which Will Go Now? With Betsy Seals
In this episode of Relentless Health Value, host Stacey Richter engages with Betsy Seals, CEO and co-founder of Rebellis Group, to analyze the future of key Medicare Advantage policies amidst a changing political landscape. They delve into four critical areas:
1. Medicare Advantage Stars Program: Examining potential changes due to recent lawsuits and the new administration’s stance on quality measures.
2. Risk Adjustment and Government Oversight: Discussing the focus on recouping improper payments and how oversight might evolve.
3. Use of Artificial Intelligence: Considering appropriate oversight for AI applications in prior authorization processes and ensuring they benefit patient care.
4. Agent and Broker Oversight: Exploring increased scrutiny over marketing practices and the dissemination of accurate information to beneficiaries.
Betsy emphasizes the importance for Medicare Advantage plans to prioritize patient value, maintain compliance, and proactively utilize data to navigate these evolving policies. This discussion provides valuable insights for stakeholders aiming to understand the future of Medicare Advantage.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP463
✉️ 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/
✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social
✭ Threads https://www.threads.net/@relentlesshealthvalue/
✭ X https://twitter.com/relentleshealth/
05:09 Will the Star Ratings program stay in this new administration?
08:08 How will the lawsuits against CMS policies play out with this new administration?
10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive?
16:22 How does AI directly impact beneficiary lives?
21:38 What’s going on now with the override payments?
27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward?
31:45 Why is it important to become more technologically savvy in compliance?
Next Episode
EP465: The Not Super Effective Contracting Industry Norm, Where Jumbo Plans and Others Wind Up Paying $10,000 for $50 Drugs, With Chris Crawford
The Hidden Costs of PBMs: How Aggregate Discount Guarantees Inflate Drug Prices. In episode 465 of Relentlessly Seeking Value, host Stacey Richter interviews Chris Crawford, CEO of RxSaveCard, about the inflated costs within the pharmacy benefits industry.
The discussion centers around a lawsuit involving J&J, highlighting how large PBMs can significantly overcharge for drugs that are available much cheaper through cash-pay options like Mark Cuban's Cost Plus Drugs.
Crawford explains how Aggregate Discount Guarantees, a common contracting mechanism, often fail to control spread pricing effectively and instead may lead to higher costs for plan sponsors and employees. The episode also covers how RxSaveCard can help employers and employees access these lower cash prices, circumventing the inflated costs from traditional PBMs.
=== LINKS ===
🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP465
✉️ 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/ ✭ Bluesky https://bsky.app/profile/relentleshealth.bsky.social ✭ Threads https://www.threads.net/@relentlesshealthvalue/ ✭ X https://twitter.com/relentleshealth/
07:12 EP365 with Scott Haas.
07:17 EP397 with Paul Holmes.
07:19 EP439 with Luke Slindee, PharmD.
07:20 EP379 with AJ Loiacono.
07:44 What is the Aggregate Discount Guarantee?
13:49 Why do the divergent list prices and the perverse incentives prevent the Aggregate Discount Guarantee from really limiting cost spread?
17:55 Why is it important for plan sponsors to check these drug cost prices, and how can employers check them?
23:56 What drives cost lower, and why does it change everything?
25:09 How does RxSaveCard work?
25:44 EP461 with Chris Crawford.
30:01 Do you need a PBM’s permission to use RxSaveCard?
30:37 How does it look for employers/employees to use the RxSaveCard?
32:39 EP356 with Ge Bai, PhD, CPA.
Relentless Health Value - EP464: ER Visits Now 6% of Total Plan Spend. Is It Upcoding or What? With Al Lewis
Transcript
Episode 464. ER, Emergency Room Visits, Now 6 Percent of Total Plan Spend. Is It Upcoding or What?" Or What Indeed. Today, I speak with Al Lewis.
American Healthcare Entrepreneurs and Executives You Want to Know, Talking.
Relentlessly Seeking Value. Today, I am speaking with the one, the only Al Lewis, and we're gonna talk about how 6 percent of a lot of plan sponsors total spend is now going to ER, ED, E
If you like this episode you’ll love
Episode Comments
Generate a badge
Get a badge for your website that links back to this episode
<a href="https://goodpods.com/podcasts/relentless-health-value-171420/ep464-er-visits-now-6-of-total-plan-spend-is-it-upcoding-or-what-with-85375032"> <img src="https://storage.googleapis.com/goodpods-images-bucket/badges/generic-badge-1.svg" alt="listen to ep464: er visits now 6% of total plan spend. is it upcoding or what? with al lewis on goodpods" style="width: 225px" /> </a>
Copy