Why Make A Federal Case Out Of A $1,300 Debt?

April 18th, 2014

“Now, why should hospitals be concerned?  Two reasons………...”confused-face2

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Texas TPA Offers Cash Plan To Medical Facilities?

April 17th, 2014

cashplan   By Molly Mulebriar

Cash is King, especially in the medical reimbursement arena. Members of the 50% Club can attest to that. (Type in “50% Club” in search box on this blog).

Hospitals offer deep discounts for cash, often better pricing than  managed care contracts. Contrary to representations of the BUCA’s,  size means nothing. A lone patient with cash can always  beat the big boys in health care pricing.

Imagine  an employer sponsored health plan transitioning to a Cash Plan and the savings to be realized. Turning plan participants into cash paying customers – Is that possible?

A Texas TPA says it is not only possible, they are doing it.”  Borrowing on the PBM method of financing, a line of credit allows the TPA to negotiate and pay facility claims quickly and efficiently.

A recent claim transaction illustrates the effectiveness of this approach. A  gross billed charge for an outpatient procedure of $12,000 was reduced to less than $2,000 with a cash pre-payment by the TPA using their own line of credit to fund the payment. At the end of the month, the TPA recouped their funds through a claim draft against the Plan Sponsor’s claim account. The PBM financing model is now extended to include medical claims.

We knew it was only a matter of time someone would think of this and actually do it. (My father invented the weed eater in 1955 but never bothered to obtain a patent, much less build one). Turning ideas into action is hard for some.

Of course, it’s not as simple as one would expect. Plan document language and stop loss contracts must mirror the scheme. But details are someone else’s problem, right Uncle Hermann?

Editor’s Note: Molly Mulebriar is a free lance reporterette from Waring, Texas.





Agent – Broker – Consultant E&O Liability under PPACA

April 14th, 2014

bareUnder-Insured Insurance Agent/Broker

Insurance agents, brokers and consultants better dust off their E&O policies and read them. There is a good chance they may not be covered in areas they need to be due to increased exposure under PPACA. For example, is there coverage for self-funded employee welfare plan sales, service and recommendations? If so, is there a policy sub- limit such as $250,000? Giving advice as a fee based insurance consultant  is almost never covered under most group E&O policies, does yours? Probably not. In fact, one would probably need to go to the surplus lines market to find adequate coverage these days. And what about cost? Standard group A&H E&O policies run around $400-$700 per year. Adequate coverage  can cost thousands of dollars per year.

Going bare is risky these days………….

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Walgreens Urged To Leave United States To Gain Tax Benefit

April 13th, 2014

By Ed Hammond in New York

Walgreens has come under pressure from an influential group of its shareholders, who want the US pharmacy chain to consider relocating to Europe, in what would be one of the largest tax inversions ever attempted.

Editor’s Note: Exporting patients and companies seems to make economic sense these days.

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AMPS CEO Featured In Business Insurance Article

April 13th, 2014


AMPS‘ CEO, Mike Dendy, Featured in Business Insurance Article: Medical bill reviews and audits can help employers lower health benefit costs

“A uniform bill is a single piece of paper or electronic document that summarizes the services provided,” said Mike Dendy, CEO of Advanced Medical Pricing Solutions, a medical bill review service based in Norcross, Ga. “It might have something like ‘pharmacy’ with no details. Every payer in the country takes that uniform bill and writes checks on their clients’ behalf.”

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Assent Medical Cost Management Launches MAXpay – A Reference Based Pricing Model

April 13th, 2014


MIAMI, FL–(Marketwired – Mar 12, 2014) – Assent Medical Cost Management (Assent) announced the launch of MAXpay, a fixed dollar reference based pricing program. Targeting Self Insured Plans, MAXpay increases control over healthcare expenses by setting reasonable and fair benefit limits. To determine reimbursements, MAXpay utilizes cost data, multiples of Medicare reimbursement and Medicare-like methodologies, all of which are fully defensible.

Editor’s Note: Cost Plus Insurance /  Reference Based Pricing is a growing market phenomenon - Xerox, Eastman Kodak And Cost Plus Insurance

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Specialty Drugs & Umbrella Drinks

April 12th, 2014


A new drug that successfully treats Hepatitis C is being hailed as a breakthrough, but is also stirring fierce debate for it’s $84,000 price tag………Compounding the issue surrounding HCV drugs is the fact that India, Egypt, and Brazil may pay just 1 percent of the U.S. price tag for Sovaldi……………..Iran, Kenya, Burma, and Mozambique have negotiated the price of $900 for a course of Sovaldi,…..“It’s unfortunate that American patients, employers, and taxpayers aren’t currently being offered a more reasonable price for Sovaldi,” he said. “It’s an issue of both public health and public solvency.”

Editor’s Note: Specialty drug costs can “break the bank” of any employer sponsored medical plan. And, specialty drug costs are hitting more and more plan sponsors these days, a growing phenomenon. We have several clients whose drug costs have soared as a direct result of specialty drug pricing. One patient, for example,  is incurring specialty drug expenses of over $150,000 per year. One group’s Rx spend now represents almost 40% of the total plan spend per year as a direct result of specialty drugs.

Dumping a patient into a public exchange is one solution to getting rid of the risk which is not illegal under PPACA, as far as we can tell (click on link below):

Business Savior – Self Insurance & Shifting Sick Workers To Exchanges

In the case of Sovaldi, perhaps a stipulation in an employer’s plan document to state that the Plan will cover Sovaldi only in India, Iran, Brazil, Egypt, Kenya or Burma. There is nothing in PPACA that specifies where drugs must be covered, is there? Kind of like an EPO or HMO – your covered but only through specified providers who happen to be located in ……..Or how about Reference Based Pricing – “We will pay $900 towards the cost of a full course of treatment of Sovaldi, you pay the difference if any.”

A plan sponsor may offer to pay for the trip  to Brazil, including beach side resort, five star accomodations,  for the duration of the treatment. Since Sovaldi is so inexpensive in Brazil, even with  air fare, lodgings and meals a plan sponsor can save 70% or more. In fact, the patient could even be given a cash reward too along with  free, unlimited number of umbrella drinks while under treatment…………….

Life can be paradise as a patient these days. On the other hand, we don’t want to encourage at risk life styles do we?

“Rather than import the drug, let’s export the patient!” – Homer G. Farnsworth, M.D.

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Another PPACA Loophole?

April 11th, 2014


Can a self-funded employer  limit risk by limiting frequency of benefits?

“Treatment limitations include limits on benefits based on the frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration of treatment. Treatment limitations include both “quantitative treatment limitations,” which are expressed numerically (such as 50 outpatient visits per year), and non-quantitative treatment limitations, which otherwise limit the scope or duration of benefits for treatment under a plan or coverage. A permanent exclusion of all benefits for a particular condition or disorder is not a treatment limitation. As explained above, classifications of benefits include (i) inpatient, in-network; (ii) inpatient, out-of-network; (iii) outpatient, in-network; (iv) outpatient, out-of-network; (v) emergency care; and (vi) prescription drugs.”  - Mintz Levin, Employment Labor & Benefits

pelosi  That’s right Nancy………………………


An In-Depth Analysis Reveals the Most Aggressive Cost-Control Strategy for ACA Compliance

April 10th, 2014


The cost of ACA compliance can be significant and it may be unmanageable for large employers who employ many lower-wage workers. That’s because these employers must offer the same ACA-compliant plans to all classes of eligible employees—from hourly workers to the CEO. However, there is a benefit strategy that can minimize this financial impact while meeting the needs of an entire workforce. It includes:

• An affordable Bronze ACA-compliant plan that still meets the “safe harbor” requirements   for all eligible employees
• A Minimum Essential Coverage (MEC) plan bundled with a limited-benefit plan offered to low-wage employees (including eligibles)
• Two levels of additional (ACA-exempt) benefits offered on a non-coordinated basis for middle managers and executives

To learn more about this aggressive cost-control approach, download Ternian’s new white paper.  Or contact usfor more information about how we can customize this approach to meet the distinct needs of your clients.

Ternian Insurance Group
(602) 216-0006


BCBS Over-Payment Practice Dealt Death Blow

April 8th, 2014
money back
This might be the first time in US healthcare history that a federal ERISA court grants a permanent injunction against a violative insurance company or health plan.