The US Court of Appeals for the Third Circuit has held that anti-assignment clauses in health plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) generally are enforceable.
Anti-Assignment Clauses Are Enforceable
May 21st, 2018Texas Healthcare Costs
May 21st, 2018
Article referred by David Wendel
The Texas Department of Insurance (TDI) has a new website that provides cost information on more than 200 of the most common medical procedures, including many tests, surgeries and office visits.
How Do You Measure Savings?
May 19th, 2018
Question: How do we know we are doing better (saving money) this year than last year?
Answer: What was this year is last year plus or minus this year’s change.
Question: Then if change is the only constant why do we need to measure it? You don’t know if something is better if you didn’t know how to measure what it was before.
AUTHOR UNKNOWN
Slippery Slope Insurance Consulting?
May 19th, 2018
By Molly Mulebriar
The City of New Braunfels RFP recently hired an insurance consultant to assist the city in a competitive RFP process for their employee health & welfare plan. Or did they hire two?
Vermont To Permit Drug Imports From Canada
May 19th, 2018
Vermont initiative creates a wholesale importation program to purchase high-cost drugs in Canada, where they often sell for less…………………Will retail Rx outlets then advertise and export these cheaper drugs from Vermont to the rest of the county? Could be a fantastic Rx mail-order business domiciled in Vermont…………….
Turning Bronze Into Gold
May 18th, 2018
Turning Bronze Plans into Gold Plans at Bronze Plan costs is a common but unspoken strategy……………
Physician Strikes It Rich in Health Care Arena
May 17th, 2018
A Texas doctor used his million-dollar private jet or drove in his Maserati, which were both emblazoned with his initials “ZQ” between his offices in the Rio Grande Valley and San Antonio…………he purchased private jets, luxury vehicles, clothing from high-end retailers such as Louis Vuitton and exclusive real estate located throughout the United States and Mexico………..all garnered through his successful clinic operation in deep South Texas………………
Medicare + Fee Schedules
May 15th, 2018
NATIONAL ASSOCIATION OF PREFERRED PROVIDERS (NAPP) Fee Schedule:
☑ Medicare plus 25% or 80% of billed charges, whichever is less.
☑ THREE RIVERS PROVIDER NETWORK (TRPN) – PPO Fee Schedule:
125% of the existing Medical fee schedule as total reimbursement for covered services less applicable co-payments, co-insurance or deductibles.
IMAGINE A ONE OR TWO PAGE HOSPITAL CONTRACT INCORPORATING THESE FEE SCHEDULES…………………….
Refried Beans
May 15th, 2018
Pointing Fingers
May 14th, 2018
Republicans and Democrats blame each other for the great American health care failure. But isn’t it true that once government gets involved in anything costs go up? For example, food costs are higher because of the food stamp industry wherein recipients really don’t care what the cost of food is since its free. And how about college tuition? With rampant student loans students (and their parents) don’t feel the financial pain……………until much later. Isn’t the same true for the high cost of health care?
OUT OF THE LAW FIRM, INTO THE ADVISORY WORLD
May 14th, 2018
“I’d like to call the employee benefits “advisory” space another one of the most respectable professions in existence, but I can’t. Advisory is in quotes because that’s not really what it is. Many employee benefits consultants are brokers, a line of work that differs sharply from what it means to be a true advisor.”
Providers Fight Back
May 13th, 2018
With the “death stars” of Amazon/Berkshire Hathaway/JP Morgan, CVS/Aetna and United/Optum moving quickly to disrupt the provider space, it is now more important than ever for providers to have effective tools to fight back………………………..
Troubled School District Seeks Insurance Consultant………….Again
May 12th, 2018
The Donna Independent School District in deep South Texas has had plenty of bad press during the past several years – board members sent to prison, hiring of convicted felons, lawsuits and counter lawsuits, sanctions by the Texas Education Agency, and now TEA oversight (Texas Border School Scandal Highlights Culture of Corruption – Breitbart).
Now we learn the DISD is again seeking yet another insurance consultant. This will make the sixth “insurance consultant” / brokers utilized by the district in less than three years………………..
Son’s Death Sparks Outrage
May 12th, 2018
Litigation Risks: The Dark Side of Reference-Based Pricing (RBP)
May 10th, 2018
RBP can save a self-funded plan a lot of money and create immense opportunity to permanently improve the benefits for employees in that plan; however, RBP can also create an environment for conflict, individual tragedy for plan members, and protracted litigation…………….
Plan Sponsors Gamble Even Though Odds Are Against Them
May 7th, 2018
The 60 Minutes story (www.cbsnews.com/video/the-problem-with-prescription-drug-prices/) aired last night illustrates the continuing gamble most plans sponsors take in not addressing high cost specialty drugs. There is not a group in this country that offers ACA complaint health care benefits for their employees that is not at risk of bankruptcy, yet they continue to gamble they will beat the odds.
Fake News Story Revised – The Power of The Press
May 7th, 2018
Last week a story ran in the Victoria Advocate (Victoria, Texas) that told the sad story of mean insurance companies bankrupting a new start up business whose goal was to service the dire health care needs of locals. See Mean Insurance Companies Bankrupt Free Standing ER.
Now the same newspaper, different reporter, spins the story in a different direction…………….
Small-Business Health Plan Rule Under White House Review
May 5th, 2018
Bill would allow more small businesses, including self-employed individuals, to form health plans on the basis of industry or geography…………………
POSCA℠
May 4th, 2018
POSCA℠ is a first in class method for processing health care claims…………………..
Bill Ebaugh 1930 – 2018
May 3rd, 2018
William Lee “Bill” Ebaugh
I have met a lot of people in the insurance business over the years, but Bill Ebaugh stands out. His knowledge and connections within the insurance industry was amazing. He was a master salesman, story teller, and visionary. His life’s experiences were something out of a movie. He attracted the best in everyone he met.
One day he called me – “Hey Bill, why don’t you do a write up on what your’e doing with political subdivisions. It needs to be published!” So with much prompting I did as he suggested.
A month later I received a call from Bill – “Bill (we are both named Bill), what are you doing on December 17th?”
“Why nothing Bill, whats up?” I replied.
“The State of Wyoming wants to see you on the 17th. You will be getting a call from the governor’s office setting up the trip at the state’s expense” he announced.
Yeah right I thought. “Bill I will wait for the call” I said and hung up the phone. I turned to my secretary and said “Bill is one hell of a joker!”
I was in Wyoming on December 17.
– Bill Rusteberg
Mean Insurance Companies Bankrupt Free Standing ER
May 3rd, 2018
In today’s Victoria Advocate newspaper (Victoria, Texas) there appears an article about a free standing ER closing down because the have “been having problems with insurance companies.” Actually the problem is not with the insurance companies. Its with hospitals gaming the system. Consumers equate free standing ERs as urgent care centers paying for services with other peoples money. An “office visit” there can cost several thousands of dollars for something as simple as a cold, insect bite or sprained ankle. The cost is so high and the profits so great it takes only 6 or 7 customers a day to reap a profit.
Yet you read the story below and come away thinking the mean, uncaring insurance companies seeking to pay as little as possible are to blame. BTW – insurance policies under the ACA cover emergencies.
The Elephant In The Room
May 2nd, 2018
Health care is the focus of a national debate that never seems to end. So called “experts” on health care delivery offer all kinds of suggestions and advice to solving the health care financing crisis in this country yet they won’t admit the journey towards solving the crisis will soon end.
In my circle, for example, the discussion centers around performance based medicine, reference based pricing strategies, point of service claim adjudication/payment, wellness programs, direct contracting, value based outcomes and more. But all secretly recognize there is an Elephant in The Room.
The Elephant in The Room is the inevitable coming of a single payer health care system to this country. It’s only a few elections away and we all know it. Americans are fed up with the high cost of health care. Many employers are simply running out of money to pay for it. The American middle class who has been bearing the brunt of the cost is a vanishing, diminishing class. Hospitals and third party intermediaries continue to raise pricing, compounded year after year well beyond true inflationary pressures. Drug manufacturers are reaping record profits on drugs that sell as much as 80% – 90% less overseas.
The experts mentioned above have the answers to solving our health care crisis and the proof to go with it but few seem to be listening………….
– Bill Rusteberg
The following article is about that Elephant:
Therapeutic Interchange
May 1st, 2018
The Academy of Managed Care Pharmacy (AMCP) supports the use of therapeutic interchange programs as a part of a comprehensive approach to quality, cost‐effective patient care. Therapeutic interchange is the practice of replacing, with the prescribing physician’s approval, a prescription medication originally prescribed for a patient with a chemically different medication. Medications used in therapeutic interchange programs are expected to produce similar levels of clinical effectiveness and sound medical outcomes, based on available scientific evidence.
AVYM White Paper Spurs New Jersey Probe Into Health Insurance Contracts
May 1st, 2018
“Based on court cases (cited in the paper), it seems apparent TPAs can and do hide ‘undisclosed’ administrative compensation fees within medical claims payments. These undisclosed fees, which can account for 30 to 60 percent of a plan sponsor’s health claims expenditures, are usually siphoned into the TPA variance account through ‘retention reallocations’ and ‘cross plan overpayment’ offsets, among other techniques………………..
Texas Court Orders Hospital to Disclose Reimbursement Rates
May 1st, 2018
The Texas Supreme Court has ruled that a hospital in Cypress, Texas, must disclose its negotiated reimbursement rates with public and commercial health plans as part of the discovery process in a suit filed by an uninsured former patient………………
World Health Care Congress Awards Continental Benefits Top Ranking
April 30th, 2018
More than 350 nominees competed to be the best to improve health outcomes, reduce costs and implement innovative health industry practices. Continental Benefits, a fast growing third party administrator won first place……………
Health Insurance Refugees
April 29th, 2018
CHARLOTTESVILLE, Va. — When Garnett and Dave Mellen sent their 19-year-old daughter, Gita, off to college an hour away at Virginia Commonwealth University last fall, they didn’t expect to follow her.
April 28th, 2018
I received this nice message yesterday. Its all about sharing ideas / information that makes us all better at delivering health care solutions for our mutual clients.
“Bill, I read your blog. In fact, you don’t know this but your blog provided me much of my initial understanding of network discounts, reference based pricing and so on back in 2015.”
Specialty Drugs Bankrupting Health Plans
April 28th, 2018
Group plan has two individuals costing the plan in excess of $500,000 per year. If any more like these crop up the plan will go bankrupt in a hurry……………………….
Do Health Care Providers Lose Money on Medicare Patients?
April 27th, 2018
On any given flight, many of the passengers paid less for their tickets than the average price-by-passenger of operating the flight………………..
Senate Bill Would End PPO’s
April 25th, 2018A new bill introduced in the US Senate, if passed, will lead to
extinction of PPO’s in this country. If consumers and plan sponsors are able to access the Medicare network at Medicare pricing, (Renting Medicare’s Provider Network) why would anyone stay with a PPO with pricing averaging two, three, or more times than Medicare pricing? Would you?
Purveyors of Reference Based Pricing strategies will rejoice because instead of paying 120% to 150% of Medicare now, they will swiftly reduce the benchmark to, at a minimum, 100% of Medicare allowable. And, I expect, some plan sponsors will tag their reimbursement to 80% of Medicare allowable as a cost sharing measure with plan members……………Bill Rusteberg
Docs Billing Medicare Patients Directly? CMS Looks to Allow It
April 24th, 2018
Listless Doctors Awaiting Word From Washington……”Sorry, we can’t contract with you until the government lets us…………….”
Entrepreneur Makes Millions in Health Care & Retires to Lush Tropical Paradise
April 24th, 2018
Immigrant strikes it big in the United States, the land of opportunity attracting millions of opportunity seeking, hard working visionaries from across the globe. This is a story of one who struck it big in health care………………….
Brokerage Firm Touts RBP Certification
April 22nd, 2018An east coast insurance brokerage has announced they are now “certified” to market reference based pricing strategies. We find this curious. How does one get “certified?” So we decided to memorialize the process here.
In response to the apparent and curious need to become certified in order to offer clients reference based pricing strategies, RiskManagers.us has developed a simple 
certification process free to anyone who wants to try it. Simply look in the mirror and chant three times “I desire to become a certified reference based pricing mogul.” Then write this blog certifying your desire to be certified and we will send you your official Reference Based Pricing Certification Certificate at no charge.
Simple Hospital Agreement
April 21st, 2018
RiskManagers.us has facilitated direct provider agreements directly between self-funded employee health & welfare plans for years. It doesn’t take a rocket scientist to do this. It’s all about common sense, traditional American business practices (as opposed to traditional managed care practices), based upon fair value for both parties.
Again?
April 20th, 2018
There have been numerous lawsuits filed over the years exposing industry secrets that drive costs up for unwitting consumers. Here is another one that just cropped up……………………
Rural Broker Contains Costs Through Hospital Partnerships
April 20th, 2018
Beth Johnson
Some people assume that because Beth Johnson’s brokerage is located in rural Missouri she is at a disadvantage when it comes to designing innovative benefit packages for her clients. They would be mistaken……………………
Tell Us Your Outrageous Health Care Stories
April 20th, 2018
Brian KlepperBenefit brokers get paid more for doing a bad job. They can get rewards for driving up spending such as trips or other undisclosed compensation………………………
New Idea For Reducing Health Care Costs Is Actually Really Old
April 20th, 2018
We have a health care delivery system where the price of health care is unrelated to the cost of providing it, or outcomes, but rather to the relative power of hospitals, third party intermediaries and medical groups to which unwitting consumers gift wealth using other people’s money facilitated through secretive managed care contracts you can see nor audit……………………
April 18th, 2018
The Cost of Convenience
“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.”
RiskManagers Partners With Prescription Care Management to Reduce Members Prescription Drug Spend
April 18th, 2018
April 17, 2018
YOAKUM, Texas, April 17, 2018 /PRNewswire/ — RiskManagers.us is proud to announce it has entered an agreement with Prescription Care Management (PCM) for members of the RISKMANAGERS HealthCare Purchasing Coalition.
Texas Insurance Broker Gets Prison Time For Bribery
April 18th, 2018
An insurance broker who admitted paying bribes to land lucrative health insurance contracts at area school districts and the now-defunct water utility was sentenced Wednesday to 37 months in federal prison…………………..
A David Contorno True Life RBP Experience
April 14th, 2018
Moved a large client (1100 employees) to Reference Based Pricing 4/1. As I expected, we had some employees who went to providers with the PPO logo removed and some said they don’t take the plan.
“Hospitals Are Only Entitled To Collect A Reasonable Fee”
April 13th, 2018
He contended that authoritative research showed that Medicare plus 25 percent was a reasonable amount for hospitals to charge………………….
Texas Lawmaker Calls on State to Fix Teacher Retirement System Care
April 13th, 2018“Teachers statewide are sharing their stories with us, hellish stories about people having to choose between medication and food, medication and rent, medication and just basic living necessities…….”
RISKMANAGERS.US:
As a Texan I am sad to admit the little tiny state of Montana took the lead two years ago and now we hear the bright red Republic of California may be doing the same with California Assembly Bill 3087. (California Assembly Bill 3087 Would Control Prices in the Commercial Market.) When will Texas legislators wake up? Has Texas Lost It’s Cajones?.
Historic Healthcare Ruling In Blue Cross Blue Shield Antitrust Litigation
April 12th, 2018
“Our case alleges that, for decades, the Blue Cross Blue Shield system has operated as an illegal association of competitors trying to suppress competition in order to inflate their ownprofits at the expense of their customers,” said Hausfeld Chairman and Co-Lead Counsel Michael D. Hausfeld.
American (Cold) Civil War Expands – Blue States Fight Texas
April 12th, 2018Democratic Attorneys General Fight Texas Over Obamacare Lawsuit
April 9, 2018 at
SACRAMENTO (AP) — Sixteen Democratic attorneys general pushed back Monday against a Texas lawsuit aimed at striking down former President Barack Obama’s health care overhaul.
California Attorney General Xavier Becerra led 14 other states and the District of Columbia in filing a motion to intervene in the Texas case and defend the law, suggesting the Trump administration wouldn’t take such action.
“We’re taking this action to protect the health and financial security of millions of people in our country, as well as billions of dollars of federal funds that go to our states to make sure that we can afford the health care that our families need,” Becerra said at a news conference.
3 Reasons Why Health Insurers and PBMs Are Merging
April 12th, 2018
“Transparency inevitably reduces margins as clients, in turn, demand a better deal as well.”
California Assembly Bill 3087 Would Control Prices in the Commercial Market
April 11th, 2018
An ambitious California bill would put the state in charge of controlling prices in the commercial healthcare market…………………………
Oklahoma Squashes Hospital Pricing Transparency
April 11th, 2018
Medical cost transparency bill dies in Oklahoma House with little support……………
Hilarious Auto Response
April 11th, 2018This blog sends out posts of interest from time to time to a select group of like minded health care revolutionaries. Today one of our three members responded via Auto Response:
I’m on vacation returning in the second half of April. 
If it is an urgent matter, please re-send your email with URGENT in the subject line. I’ll be on the lookout for those. Or you can send email to XXXXXX If it’s really urgent, you call also call/text my cell phone.
Or if you prefer, choose from one of my alternative out-of-office messages below
Primary Care Clinics On Road To Extinction?
April 11th, 2018
Primary care physicians saw office visits fall 18 percent from 2012 to 2016…………….
Pharmacy Associations Urge Congress For Hearings on PBMs
April 10th, 2018
“Pharmacists have long been concerned with pharmacy benefit managers operating as largely unregulated middlemen in the drug supply chain………………..”
Blue Cross Antitrust Suit Moves Forward
April 10th, 2018
Blue Cross Blue Shield could be in trouble following a federal court ruling that an antitrust case against the insurer can proceed……………..
Region One Education Service Center Awards TPA Contract
April 10th, 2018
The Region One ESC Board of Directors has awarded third party administration services to Frates Benefit Administrators…………………………….
MedZERO Launches Partnership with Asserta Health
April 9th, 2018
The partnership will enable Asserta Health’s customers–self-insured companies and their employees–to benefit from the significant discounts associated with upfront cash payments…………..
Texas School District RFP Seeks Honey Pot Administrative Services
April 8th, 2018
The district’s self-funded health plan is a multi-million dollar honey pot, attracting the worst of the worse in innovative brokerage tactics that make one’s hair stand up……………….
Lockton Acquires Benefits Administration and Enrollment Firm
April 7th, 2018
The acquisition will allow Lockton to expand its benefits administration, enrollment and employee education services and tools for clients of all sizes and demographics………..
April 6th, 2018
RiskManagers HealthCare Purchasing Coalition 2018
RiskManagers HealthCare Purchasing Coalition ™ is a high performance health care Management Services Organization founded on a simple proposition: Health care cost can be reduced while maintaining or even improving benefits at the same time.
TPA Did Not Breach Fiduciary Duty Court Rules
April 6th, 2018
No Breach of Fiduciary Duty for Health Plan TPA That Overpaid Claims for Participant Eligible for ESRD-Based Medicare
Schuessler Rocks!
April 6th, 2018
Historically, Employers and their “Brokers” have focused on the wrong 20% of the healthcare dollar (Fixed Costs)……………………
Will Hospital Continue To Honor RBP Safe Harbor Provider Agreements?
April 6th, 2018
St. David’s HealthCare acquires The Austin Diagnostic Clinic………….
RISKMANAGERS.US OPINION: Austin, Texas is basically a two hospital town. Both hospital systems have tried their best to discourage local employers from implementing Reference Based Pricing plans in recent years. After all why agree to earn less when secretive managed care contracts continue to pay top dollar? Other area providers such as Austin Diagnostic Clinic are known to have entered into direct agreements with Reference Based Pricing plans in the area at rates slightly above Medicare. Will St. Davids continue to honor these agreements?
Restaurant Association Launches Association Health Plan
April 5th, 2018
The National Restaurant Association’s new Restaurant & Hospitality Association Benefit Trust, designed for restaurants and hospitality businesses with fewer than 100 employees, comes at a time when association health plans are a major topic of debate in Washington.
Do Corporate Dental Chains Screw Indigent Patients?
April 5th, 2018
Corporate dental chains see big profits in adults who can’t afford care…………….
Teachers Are Pissed
April 3rd, 2018
Kentucky and Oklahoma teachers flood state capitals — and refuse to back down until their demands for pay raises are met. What little do they know is the biggest pay raise they could achieve is smarter management of their health insurance plans…………………………The savings would be immediate, paychecks would increase and benefits would be improved at the same time. It’s found money for the states……………
Walmart-Humana – Next Disruptor in Health Care?
April 2nd, 2018
It has been a busy few months tracking all the merger/acquisition/partnership announcements in the health care market…………………………
Direct Primary Care Legislation Rolls Across the Country
April 2nd, 2018
Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee……………………
PPO Escalator Clause Directly Attributable to Medical Trend Factor
April 2nd, 2018
Employer-sponsored medical plan costs expected to rise 8.4 percent…………..Cost of health care is essentially static but the cost of health insurance is not thanks to escalator clauses (Escalator Clauses, Rising Prices, And Why We Should Care) found in all managed care contracts guaranteeing pay raises every year for most medical caregivers…………..
Why on earth do plan sponsors continue to rely on managed care contracts they cannot see nor audit yet continue to complain about rising health insurance costs? Their answer – Blame consumers, cost shift to plan members and continue to use PPO networks………………..
Well Managed Health Plans Outperform Status Quo Plans
April 2nd, 2018
Best performers stand out from their high-cost peers in the rate at which they adopt new means of delivering health care………………..
Blue Cross Files Bankruptcy
April 1st, 2018
Shock report from BCBS national headquarters……………………..Mass suicide watch – 45 BCBS sales representitives feared dead…………….National Guard called to active duty…………..Trump expected to address nation tomorrow………………..
Burger King In Acquisition Talks With Blue Cross
March 30th, 2018
FOR IMMEDIATE RELEASE
Burger King In Acquisition Talks With Blue Cross
Scottsdale, Az – (March 30, 2018) – Burger King, home of the nation’s best, highest in saturated fats mouth watering burgers announced today they are in advanced discussions with Blue Cross on a possible merger.
What Advisers Should Know About The First Reference-Based Pricing Lawsuit
March 29th, 2018
In Martinsville, Virginia, there is a reference-based pricing lawsuit pending that industry insiders are watching closely, because it could set a precedent for these types of lawsuits moving forward. In this case, a Virginia hospital has been pursuing an $84,000 balance bill from a former patient for nearly four years and through two separate courts……………………
Health insurers, Big Pharma Play Blame Game Over Drug Prices
March 28th, 2018
Health insurers and pharmaceutical companies are pointing fingers at each other for the rising cost of prescription drugs as scrutiny over drug spending intensifies………………..