You Have to Use These Codes. The AMA Charges You to Read Them.

Health lawyer Barbara Zabawa had me on the Wellness Law Podcast to talk about the AMA’s grip on billing codes, and what employers can do to stop paying for a broken system.

Barbara Zabawa found me after she read my Substack article discussing the American Medical Association getting sued over its billing codes.

If you know anything about the bogus practices of the AMA, you can imagine why she reached out.

When she reached out to ask if I’d join her podcast, it was an easy yes.

You see, Barbara has spent her career building a practice area most lawyers have never heard of: the legal rules for people who want to keep you healthy instead of billing you for being sick.

She founded the Center for Health and Wellness Law, wrote the American Bar Association’s book on workplace wellness programs, and teaches health law at UM-KC. She also once worked in-house at a large health insurer, so she knows exactly which rooms the bodies are buried in.

We started with the AMA.

You probably think of it as the nice little trade group for your doctor down the street. Most people do.

Well, it’s a scam, and a very profitable one.

Every medical bill in America is written in CPT codes. Medicare requires them. They’re part of the infrastructure of HIPAA-compliant billing. No employer plan will pay a claim without them. They are, for every practical purpose, law.

But the AMA owns them.

It makes roughly $300 million a year on the codes, and providers pay for access to the words they are required to use.

My friend Cynthia Fisher runs PatientRightsAdvocate.org. I worked with her on the price transparency rules when I was at the White House. Hospitals and insurers now have to post their prices, and they love to post them in file formats your computer can’t even open.

Cynthia’s team converts those files into spreadsheets actual humans can read.

And those spreadsheets contain CPT codes.

So now we’re fighting over whether a private organization gets to charge the public for access to something the government requires everyone to use.

Cynthia sued the AMA. (My money’s on Cynthia.)

We also got into what I do at AllBetter.

Health care is often the number two line on an employer’s P&L, and it climbs by double digits every year. Any other line item behaving like that would get the vendor, the product, and the account manager fired.

Instead, HR renews the Blue Cross plan, because nobody ever got fired for buying Blue Cross, on the advice of a broker who is paid by the sellers.

A reminder: Blue Cross is not reaching into its own deep pockets to pay your medical bills.

It’s reaching into your employer’s.

So we fire the carrier. We fire the PBM. We rebuild the plan with independent vendors who are paid by the employer and nobody else.

The thing I like to say that makes CFOs ask 100 more questions is that the only way we’ve found to save employers money is to make the benefits more generous.

• Concierge primary care.

• A nurse navigator for every group.

• Deductibles waived when you go to the high-quality site.

Barbara asked where corporate wellness fits.

Wellness 1.0 paid the healthiest employees a premium discount to check boxes they were going to check anyway, while 5% of the workforce drove half the claims.

That was never going to work.

Wellness 2.0 is primary care that owns the patient.

And direct primary care is finally starting to bill as a claim, which sounds boring and changes everything.

I work with Catholic priests scattered across the country. Our nurses can now drop a priest into a DPC practice in any town without negotiating 200 separate contracts.

That’s how direct primary care starts to scale.

Wellness 3.0 is the functional labs, the nutrition counseling, the naturopath, the acupuncturist.

All the ways to keep people well that don’t require writing a giant check to a giant corporation called “Saint Whoever” down the street, pretending to be a charity.

Give it a watch.

And if you run a company and you’re tired of watching that number two line eat your margin, come find me at AllBetter.