Billed Charges vs PPO Allowed Charges vs Cost Plus Insurance

May 26th, 2016

cost plus

By Bill Rusteberg

A random sampling of hospital / facility claims incurred in the Lower Rio Grande Valley, Texas (The Valley) illustrates the crazy world of health care pricing strategies.

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Dereliction of Fiduciary Duties Triggering DOL Investigations

May 26th, 2016
bernie

“The penalties for this type of fraud should be severe. All benefits leaders and their consultants should be overhauling how they manage care and cost, or risk the consequences. It’s particularly notable that the Department of Labor is now arguing that fiduciary dereliction in health benefits is rampant.” – Brian Klepper

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Annual Healthcare Costs For Families Hit $25,000

May 26th, 2016

As health care costs escalate, Cost Plus / Reference Based Pricing plans gain traction within the employer community…………….

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Memorial Day 2016

May 25th, 2016

 rusreberg

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.

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Moving Patient Payment Upfront

May 24th, 2016

highdeductibleHospital systems are beginning to screen patients in high-deductible plans for their propensity to pay. And for those who can, they are developing systems to collect in advance of care.

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New Approved FDA Drug Costing $1 Million A Year?

May 22nd, 2016

cigarette1

More and more employers are eliminating specialty drug coverage entirely. They really have no choice.

Imagine a small employer group of 250 employees assuming outright the risk of $1 million for Smoker Smith who now has lung cancer and is taking one of the new specialty drugs costing $85,000 per month. There is no way for the employer to continue his group medical plan. 

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The OPEC OF Healthcare

May 21st, 2016

dendy

Mike Dendy, MBA, MHA

“OPEC laughed at the US and the rest of the world when we complained that $120 per barrel oil was choking the life out of business and the public in general around the world.  Rather, they built ski mountains in their deserts out of the rest of the world’s money and threatened to drive oil prices even higher. ”  

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HealthSmart Announces New CEO of BridgeHealth

May 21st, 2016

healthsmart ge

(May 17, 2016)—HealthSmart announced today that Mark Stadler has been named CEO of BridgeHealth, effective June 1, 2016. Mark joined HealthSmart in September 2011 and has been the leader in our commitment to price transparency and empowering our members to become savvy healthcare shoppers.

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David Belk

May 19th, 2016

belk David Belk, M.D.

Hello. It’s time for another chapter on the many ways in which our health care system is a total mess.

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Surge In Drug Prices Zinging Some Health Insurers

May 19th, 2016

drug12

In an Oct. 5 report, The Wall Street Journal noted that prices for the 30 best-selling drugs last year had gone up an average of 76 percent since 2010 – eight times faster than general inflation.

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Plan Sponsor Guilty of Breach of Fiduciary Duties?

May 19th, 2016

horseSome plan sponsors hire a third party administrator to manage costs. Others hire third party administrators to process claims.

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Highmark Sues U.S. Over Affordable Care Act

May 18th, 2016

indiangiver

“All we’re asking is for the federal government to do what they promised” – David Holmberg.

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Low Cost Software Tool for Medicare Reimbursement Strategies

May 17th, 2016

rbrvsNeed a low cost Windows solution for creating and managing Medicare and other RBRVS based fee schedules?  Try RBRVS EZ-Fees…….

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Blue Cross Blue Shield Enrollment Office

May 17th, 2016

bcbsenrollmentoffice

Blue Cross mobile enrollment office – when gas was 17 cents, and health insurance was affordable

Playing Doctor

May 16th, 2016

playingdoctor

In a deep dark recess of today’s Federal Register, large corporations just quietly received permission to “play doctor” with their employees.

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Cash Pay Plans Make Sense

May 16th, 2016

flying

“Those who say Cash Pay Plans are pie-in-the-sky dreams are mistaken. If man can fly then so can Cash Pay Plans.”

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Nothing Makes Sense In Health Care Financing

May 16th, 2016

confused“In the world of group health insurance, in order to reach the best financial outcome, you often have to depart from the realm of logic, reason and actuarial principles.”

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BREAKING: High Court Punts On ACA Birth Control Battle

May 16th, 2016

birthconbtrol

Will Religious Institutions Be Required To Fund Against Their Will?

By Jeff Overley

Law360, New York (May 16, 2016, 10:35 AM ET) — The U.S. Supreme Court on Monday sent a long-running battle over the Affordable Care Act’s contraception mandate back to lower courts, directing the Obama administration and religious nonprofits to work out a compromise.

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Is HealthSmart For Sale?

May 13th, 2016

mulebriar

Is HealthSmart TPA for sale? Word on the street says it is so.

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Texas Gets 1115 Waiver Extension

May 13th, 2016

waiver

Hidalgo County health officials breathed a sigh of relief after the federal government last week extended the state’s 1115 Waiver program that provides hundreds of millions of dollars for health care services throughout the county.

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Multi-Tier Provider Networks

May 11th, 2016

curtain

“Multi-Tiered provider networks will work best if an employer creates their own proprietary network on a direct basis rather than rely on third party intermediaries. Here is how it would work: Area providers are invited to enter into direct agreements with ABC Fence Company. They are given three choices: Tier 1 – 100% of Medicare, Tier 2. 125& of Medicare and Tier 3. 150% of Medicare. Plan participants who use Tier 1 providers pay less out-of-pocket than if they had used Tier 2 providers. Using Tier 3 providers would take economic courage.”  – Homer G. Farnsworth, M.D.

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Rx Clawback Scheme Fleeces Customers

May 10th, 2016

clawback

Companies are charging copays that exceed the customers’ costs for their drug. Pharmacists call it a clawback – the company is essentially clawing back money from you and, our source tells us, you probably don’t even realize it’s happening. “They have no idea,” the pharmacist says.

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Austin Texas Pharmacy – “We Don’t Deal With Insurance Companies”

May 9th, 2016

MedSavers Pharmacy

Medsavers Pharmacy is a family owned and operated pharmacy in Austin, Texas founded in 2005 on the principle: “we don’t deal with insurance companies.”

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Wellcentive – Transitioning to Value Based Care

May 9th, 2016

wellcentive

Quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care.

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Shifting Risk To Hospitals & Physicians -Episodic Bundled / Fixed Pricing

May 9th, 2016

bundledpayment

As Medicare and private insurers continue to struggle with implementing accountable care organization- and population-linked payments, an increasing amount of attention is being paid to a less expansive but almost as complex method of shifting risk to hospitals and physicians: paying a fixed price for an episode of care, or bundling.

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Continental Benefits – The Purple Cow

May 9th, 2016

purple cow

Continental Benefits is one of the fastest growing TPA’s in the United States. Founded in 2013 this national TPA is committed to reducing health care costs 25% and more. And they are doing just that.

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Changes At Maxor

May 8th, 2016

maxorpharmacy

New CEO takes charge………….Maxor to exit correctional pharmacy services?

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Ruben Edelstein

May 7th, 2016

edelstein

By Bill Rusteberg

Ruben Edelstein practiced managed care in his own way. The son of immigrants, he ran a successful furniture business in deep South Texas. An astute businessman, he grew the business with locations throughout the Lower Rio Grande Valley.

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Anthem CFO To Resign

May 6th, 2016

resign“The timing of DeVeydt’s resignation may “generate uncertainty among investors until fully understood”

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Crazy World of Health Care Pricing

May 5th, 2016

southwestairlines

Why should you pay more to go to The Valley than the knuckle head sitting next to you?

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Aetna Selfies

May 5th, 2016

Enter Aetna, which is making its foray into this space with “Aetna Funding Advantage,” available to groups with as few as 10 employees.

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Businesses Opting For Freelancers To Dodge Government Punishment

May 3rd, 2016

freelance“Spurred by competitive demands for more agile organizations, the world of work is pivoting to a blended workforce………..nearly 40 percent of top performing firms already have more than 30 percent of their labor force composed of contract/freelance workers.”

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County Demonstrates Political Courage To Challenge Local Provider Community

May 1st, 2016

bot“The leadership of Botetourt County has, like many municipalities, been searching for innovative ways to reduce their health costs without increasing deductibles and co-pays to the members….”

Botetourt County, Virginia and San Patricio County, Texas have something in common – the political will to seek innovative strategies to rein in ever increasing, tax payer supported, health care costs for their employees. Challenging the status quo within their respective local health care community takes a rare political courage to prevail – Bill Rusteberg

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Affordable Health Care Is Just A Road Trip Away

April 29th, 2016

normanrockwel

People travel to visit family and attend business meetings, so why not travel for medical care?

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Specialty Drugs

April 29th, 2016
mulebriar
Bill, I have confirmed that a plan sponsor may exclude specialty drugs and remain ACA compliant – Molly Mulebriar

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Regulators Scrutinize Reference Based Pricing Plans – Phia Group To Host Webinar

April 28th, 2016

PHIA“Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now……”

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CVS Buys Target Pharmacies, Jacks Up Prices

April 28th, 2016

drug12

Walmart, Kmart, Safeway, and Kroger all charge $45 for the sildenafil, using the discount card, while Walgreens charges $450 and RiteAid $1,000…………

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Challenge To ‘Balance Billing’ Hits Hospital

April 27th, 2016

Virginia Lawyers Weekly

By: Peter Vieth April 22, 2016

For what may be the first time in Virginia, a judge has ordered a hospital to slash its “balance billing” charges by 75 percent to reflect the hospital’s usual write-off for uninsured patients.

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Specialty Drugs

April 25th, 2016
drugs1111111
QUESTION: Can a plan sponsor completely eliminate specialty drugs and remain ACA compliant?

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The ACO Delusion

April 25th, 2016

delusion

“We have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. …….The biggest sin the ACO’s commit is to distract from any real conversation about cost…………  “

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Punishment Phase of ObamaCare Begins

April 25th, 2016

helpyouGet ready. Government men are spreading out over the fruited plains seeking to mete out punishment to employers who sponsor self-funded employee welfare plans……….

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Jeanne Pinder – Health Care Revolutionary

April 25th, 2016

pinder

In the first two days, we had visits from the Florida Legislature, the Florida Department of Insurance, the Florida Department of Health, Humana, UnitedHealthCare, Cigna, Aetna, the Blues, and a range of Florida hospitals.

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In the Market for Fetal Body Parts, a Baby’s Brain Sells for $3,340

April 23rd, 2016

baby11111

A researcher paid a middleman procurement company $3,340 for a fetal brain, $595 for a “baby skull matched to upper and lower limbs,” and $890 for “upper and lower limbs with hands and feet.”

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Can A Health Plan Exclude Specialty Drugs?

April 23rd, 2016

sixtyfourdollar

The $64,000 Question

Can a plan exclude specialty drugs? The answer is yes. Many PBM’s limit their specialty drug formularies. But, can a plan eliminate all specialty drugs and remain ACA compliant?

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David Belk Publishes New Conclusion Regarding Health Care Costs

April 22nd, 2016

belk

How did we get here and why is this so hard to fix?

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Short Term Medical Insurance – How To Beat The System

April 22nd, 2016

realy

John Smith Stunned By Cheap Medical Premiums

Nothing like screwing insurance companies….…………

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Meet The World’s 16 Insurance Billionaires

April 21st, 2016

check

Petr Kellner got his start in the early 90’s selling office supplies……………

This year’s billionaires with connections to the insurance industry include the son of a Chicago meat-packer, a former appliance door-to-door salesman, a World War II flight navigator and a passionate environmentalist.

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Arlington Healthcare Group

April 21st, 2016

arlington

Arlington Healthcare Group is an established healthcare industry consulting and professional services firm. We help healthcare providers, payers, and industry technology and service enterprises grow and optimize performance and value.

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SWBC – A Texas Based Success Story

April 19th, 2016

swbc

The insurance and financial services company opened its doors 40 years ago on April 1, 1976, by principals Charlie Amato and Gary Dudley with only $1,500 in capital……“When we started this company, we had no idea of the incredible journey it would take us,” said Charlie Amato, chairman and co-founder……..

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Do Healthcare Costs Shift to Work Comp?

April 19th, 2016

confusedYes. Higher reimbursement rates for treatment under workers’ comp encourage doctors to classify injuries as work-related.

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ACA’s Unintended Consequences: People Buy Short-Term Policies

April 19th, 2016

shortWant to save as much as 75% or more on your health insurance premium costs? Try a short term medical policy.

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Government Approves Corn Tortillas

April 19th, 2016

mexicanfood

Enchiladas, tostadas, tacos – getting hungry yet? Grab a cerveza and read on.
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Were Out Of Here!

April 19th, 2016

monkey

Sam Crafting, Health Care Editor – New York Times

“A business that operates at a loss should raise it’s prices” – Sam Crafting

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Cost Plus Insurance Evolves – What A Difference 5 Years Makes

April 17th, 2016

Branson

“Don’t bother doing something unless your radically different from the competition” – Richard Branson

By Bill Rusteberg

Reference Based Pricing, or Cost Plus Insurance has evolved over the past seven years from simply re-pricing claims based on established benchmarks such as Medicare pricing schedules, to a number of evolving hybrids. A Cash Pay Health Plan Option is one, quickly gaining market attention among health care revolutionaries.

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Enrollment In Provider-Owned Health Plans Is Rising

April 17th, 2016

Enrollment in provider-owned health plans is rising

“It’s clear hospitals view owning a health plan as a way to build their population health programs by combining medical claims and clinical data.”

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New Health Plan Lowers Cost For Students

April 16th, 2016

iowastate      The change benefits students and visiting scholars with reduced premiums, but the new model also offers advantages to Iowa State as a whole.

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Insurers Warn Losses From ObamaCare Are Unsustainable

April 15th, 2016

odds1

Actuary Panics – Pleads for Mercy

“There are enough people enrolled at this point that the market is sustainable. The premiums were just too low.”

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Rick Scott Signs Law Shielding Patients From Balance Billing

April 15th, 2016

RickThe movement to protect consumers from surprise medical bills won a major victory Thursday when Florida Republican Gov. Rick Scott signed a bipartisan bill that will exempt patients from having to pay balance bills from out-of-network providers in certain situations.

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The Phenomenon of Reference Based Pricing – Are Cash Pay Plans Next?

April 14th, 2016

By Bill Rusteberg

Reference Based Pricing for health care has become the fastest growing trend in the American health care delivery system. Insurance agents, brokers and consultants upon which health care payers depend for market distribution, are joining the health care Reference Based Pricing revolution in droves. Selling health insurance is becoming fun again. Competing for business has reached new levels of intensity.

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The Science of Choosing Wisely — Overcoming the Therapeutic Illusion

April 14th, 2016

gambling

Gamblers consistently overestimate the control they have over outcomes, both in gambling and in everyday life. Their belief leads them to engage in seemingly bizarre or ritualistic behaviors such as throwing dice in a certain way or wearing specific colors…….. the illusion of control is widespread, and its effects may be enhanced when people are placed in positions of authority or subjected to time pressure or competition………….

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Overcoming Stigma Essential to Improving Payer Coverage for Obesity

April 13th, 2016

obese“Only 5% of patients with obesity who lose weight keep it off. Coverage for obesity drugs is improving, but remains uncommon. Only a tiny fraction of the candidates for bariatric surgery have the operation, in part because 70% of physicians won’t give referrals.”

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The Cost of Insurance Denials

April 12th, 2016

belk David Belk, M.D.

Hello everyone. Once again, it’s time for another case study on how our health care industry is robbing us blind.

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Region One Educational Services Center Seeks TPA

April 9th, 2016

regionn one

Region One Educational Services Center, hereinafter referred to as “ESC”, desires to solicit proposals for various firms to perform as a Third Party Administrator for the ESC’s Cafeteria Benefits Plan (IRC Section 125), Flexible Spending Accounts and Dependent Care Spending Accounts.

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Doctor Shortages? Cut Tax Rates

April 9th, 2016

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Traditional Providers Get Into the Urgent-Care Game

April 9th, 2016

urgent12

“Over the past two years, hospital chains and insurance companies have snapped up urgent-care centers in a spate of mergers and acquisitions.”

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Healthcare Initiative is Changing the Way Hospitals Do Business

April 9th, 2016

hospital bill

“Chronic diseases that require lifetime treatment and symptom management account for approximately 86 percent of all healthcare expenses…”

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Bid Rigging and Collusion in South Texas

April 6th, 2016

wolf2

“It’s a common practice but it’s wrong.” – Arnulfo Olivarez at his 1/24/2011 sentencing for bribery before Judge Hinojosa.

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Top Ten Lessons Of A Reference Based Pricer

April 6th, 2016

PHIA“As someone that has made a career trying to help healthcare providers and health plans get on the same page as it relates to cost-containment initiatives, I have compiled my personal top ten lessons about RBP from 2015.” – Jason C. Davis

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Insurers Cut Commissions

April 5th, 2016

beggar

Former Health Insurance Broker

“Some insurers, including Anthem and Humana, say they dropped commissions to keep rates down.”

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Fixing Systemic Conflicts of Interest In Broker Adviser Models

April 4th, 2016

conflictofinterestThe proposal attempts to address what DOL and the White House claim are systemic conflicts of interest in broker advisor models………….The proposed rule clearly favors fee-based compensation models for advisors…………….

Although the proposal targets pension and investment advisers per se, the same standards may be applied to fee based insurance consultants – Molly Mulebriar

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Texas TPA Purchases Entire City

April 1st, 2016

waringA large Texas TPA has announced the purchase of the city of Waring, Texas.  City officials say the sale was in response to an eroding tax base and high debt. Waring was settled by Bosnian Serbs in the mid 1800’s.

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Are Insurance Consultants Unbiased? Or Does Money Affect Behavior?

April 1st, 2016

untouchables

The Untouchables

“There have been numerous stories over the years, published widely, regarding “double dipping” by fee based insurance consultants. The scheme is lucrative, with little chance of punishment…..”

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FBI Says School District Consultant Helped Insurance Broker Get Contracts

March 31st, 2016

William O. Haff leaves the John Wood Federal Courthouse Thursday March 31, 2016. Haff pleaded guilty to conspiracy to commit wire fraud stemming from an F.B.I. public corruption investigation. Photo: John Davenport /San Antonio Express-News / ©San Antonio Express-News/John Davenport

William O. Haff leaves the John Wood Federal Courthouse Thursday March 31, 2016. Haff pleaded guilty to conspiracy to commit wire fraud stemming from an F.B.I. public corruption investigation.

William Oliver Haff, 46, of San Antonio admitted that while working for the consulting company hired by the school districts — Wortham Insurance and Risk Management — he was also getting paid on the side by an insurance agent/broker so its clients would land contracts to provide employee insurance there.

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Will The Anthem-Express Scripts Battle Change The PBM Landscape?

March 31st, 2016

battle

After months of public frustration, Anthem sued Express Scripts  Monday for more than $15 billion. Anthem argued the St. Louis-based PBM did not share enough drug savings with Anthem, which led to “an obscene profit windfall” for Express Scripts, according to a copy of the lawsuit (PDF).

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ACA – The Individual Mandate Does Not Exist

March 30th, 2016

what1

SOURCE: Benefitrevolution.com

“You can simply “believe” that Obamacare plans are too costly or experience any of another limitless form of hardship and get yourself out of the law.  So in reality, the 4 million Americans that are estimated to pay this fine should receive an “F” in creative writing and imagination. The individual mandate does not exist.  It is a mirage.”

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