Stop Loss Claim Nightmare

September 30th, 2020

Busy Jill – She Had 18 Children In Less Than 10 Years

Not too many plan sponsors have ever conducted health plan dependent eligibility audits leaving them at risk of stop loss claim denials. If Little Johnny is the covered employee’s nephew, with the same last name, has a stop loss claim you can rest assured the stop loss carrier will determine they are not at risk leaving the plan sponsor eating the entire claim……………A ticking time bomb waiting to happen…………….

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DART – Dallas Area Rapid Transit RFP for Pharmacy Benefits Consultant

September 29th, 2020

Dallas Area Rapid Transit is a transit agency serving the Dallas–Fort Worth metroplex of Texas. It operates buses, light rail, commuter rail, and high-occupancy vehicle lanes in Dallas and twelve of its suburbs. Wikipedia

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Small Business Stabilization Program by United Advantage

September 28th, 2020

First Financial Targets Texas School Districts

September 28th, 2020

“First Financial has engaged key partners in our market to provide access to the best and most immediate solutions available to Texas schools.”

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Is Opopira on Your Rx Formulary?

September 28th, 2020

Twin brothers invented Opopira, considered a miracle drug back in the day, a pasty mass consisting of a drug mixed with sugar and water or honey suitable for oral administration. This complex compound drug was used to treat diverse maladies including paralysis. 

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$1 Tele-Health Visit

September 27th, 2020

Sam’s Club and 98point6 are partnering to offer members $1 telehealth visits…..

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Imagine If There’s No PBMs – Its Easy If You Try

September 27th, 2020

Once upon a time there was no such thing as a PBM…………………….

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September 26th, 2020

“Healthcare is the only expense line item in which all employees receive an unlimited budget…and also no training in how to spend it. That’s why they sign up for $2500 procedures when a $75 solution would do the trick.”  – Dave Chase

“Hiding Cost of Healthcare an ‘Insult to Americans”

September 26th, 2020

 “When the patient gets the bill, it looks like the insurer haggled on their behalf. Yet the final charge is still much higher than it should have been. The patient loses, while the insurer and provider win.” – Nikki Haley

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Free Rx

September 26th, 2020

Trolling the internet on Chinese Flu quarantine day # 267 (and counting) we came across a website touting “Free Rx.” As we suspected, it was just another third party intermediary offering to assist consumers in applying for Rx manufacturer assistance programs. For a fee of course.

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Dan Crenshaw’s Band of Brothers & Sisters Pledge Healthcare Reforms

September 25th, 2020

Health Care:

We will fight for personalized, affordable health care that puts YOU in control, not a government takeover that puts a bureaucrat in control.

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TRS ActiveCare Enrollment / Financial Projections

September 24th, 2020

What are the statistics for TRS plan year 2020-2021? How many employees have moved over to heretofore illegal, competing commercial health plans and away from the state sponsored TRS ActiveCare government plan? What is the financial impact?

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Supreme Court To Hear PPACA Challenge With or Without New Justice

September 24th, 2020

Single payer system by 2028? Will Republicans embrace Obama Care as the better of two evils? Will whatever the Supreme Court decides have little effect on political realities?

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Charlie Meets The Tyler Rose & He’s Glad He Did………….

September 23rd, 2020

After talking with The Tyler (Grow Some Balls) Rose, Charlie was convinced he could achieve his goal of creating a better health plan — one his 150 employees deserved……………

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Dave Chase Announces Newest Book Release

September 23rd, 2020

I’ve been hard at work on something I’m very proud of: a roadmap for communities, large and small, to restore hope, health and well-being.

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Low Bid Gets The Business

September 22nd, 2020

Beginning an initial dialog with “How much will you charge us” is never a good indication things will go well with your chances of gaining a new client as long as pricing is the driving consideration.

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Whoa…………………..

September 18th, 2020

RAND stokes hospital pricing transparency fire with new report

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10 Most Common Procedures in ASCs

September 18th, 2020

Angie Stewart – Friday, January 10th, 2020

Eye and gastroenterology procedures are some of the most common services proliferated in ASCs, according to a March 2019 report by the Medicare Payment Advisory Commission.

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Emancipation Proclamation

September 14th, 2020

Freedom from high drug prices…………………………………..

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King Murray

September 13th, 2020

Murray was a most amazing character and ended up selling me life insurance….. at 27 years old!

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Ballot Box, Courtrooms & Smoke Filled Rooms

September 13th, 2020

The future of healthcare will be decided via the ballot box, court rooms, and congressional halls.

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MGU Founded Aboard Love Boat

September 13th, 2020

Love Boat Cruise Spawns MGU……………………………

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Another Austin Insurance Insurance Startup Raises $20,800,000

September 13th, 2020

Austin Startup Sana Benefits Raises $20.8M to Provides Self-funded Health Insurance to Small Businesses

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Austin Insurance Startup Raises $10,000,000

September 13th, 2020

Austin-based health insurance startup Decent has raised $10 million as it looks to expand statewide.

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Managing The Cost of Risk vs. Insurance Brokerage

September 7th, 2020

For Fairly, the real story – and challenge– is not about insurance markets; rather it is about risk management.

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Meet Bind – Health Insurance For Companies

September 5th, 2020

With Bind, costs and choices are transparent and easy to compare. There is no deductible or coinsurance to meet before the plan starts contributing, and members can change and shape their coverage as their health needs change.

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Reduce Healthcare Costs by Offering a ‘Free’ Option

September 5th, 2020

If you had a group of employees traveling on a business trip and you told them they’d only need to pay a $100 contribution toward the hotel room, what’s to stop them from choosing a Ritz Carlton over a Days Inn? Both provide a decent night’s sleep, but one will cost you, the employer, a significant amount more.

This is what manufacturing firms are doing now with their benefit plans

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Aetna Touts Cheap “I-35 Discount Providers”

September 4th, 2020

Our discounts are the best!” says a BUCA rep. “No, ours is!” responds a competitor.

“Holy Smoke guys, we’ve singled out our cheapest providers,  much cheaper than all the others,  20% cheaper! We call it the  I-35 Performance Network.” says the Aetna rep.

“That’s weird” says the RBP broker. “Why pay providers differently unless there is a difference?”

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The 50% Club

September 3rd, 2020

“I Was Raised To Pay My Debts On Time…………..”

Members of the 50% Club subscribe to the Upside Down Economics of Health Care. They understand those who pay on time are screwing themselves and those that don’t are rewarded…………….

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Protection Money Scheme Dominates HealthCare

September 3rd, 2020

Pssst…Godfather, Mulebriar Is At It Again!

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The Fallacy of PPO Re-Pricing Exercise

September 3rd, 2020

Each time I see a Request for Proposals put out by insurance consultants requiring a PPO Re-Pricing Exercise in an effort to determine which network has the best discounts the temptation to reach out to Jose Cuervo is tough to ignore. 

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GoodRx Files To Go Public

September 2nd, 2020

GoodRx’s profitability is a rarity among start-ups filing to go public……………..

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Everything You Need To Know About GoodRX

August 30th, 2020

When you go to fill a prescription, do you present your health insurance card at the pharmacy and assume you’re getting the lowest price? You may be paying too much. The cash price for many prescription drugs — especially generics — is often less than insurance co-pays.

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GoodRx Files To Go Public

August 30th, 2020

GoodRx, a digital health startup that helps users track prescription drug prices, filed for an IPO on Friday. The company hasn’t yet priced its shares, but plans to be listed on Nasdaq as “GDRX.”

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Lisa Allen Invited To Join DOL ERISA Advisory Council

August 28th, 2020

Allen is Only Expert Chosen to Represent the Insurance Industry…………

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MedSave Management LLC Announces New Program

August 28th, 2020

 

Effective September 1, 2020 MEDSAVE will be improved to include a new plan option members may choose when seeking medical care.

All patient financial responsibility for covered medical expenses will be waived each time a member requests plan assistance in selecting high quality medical providers and services.

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Very Smart Risk Management Strategy for Texas School Districts

August 27th, 2020

TSHBP offers Texas school districts a TRS ActiveCare alternative for 2020-2021 school year. A careful review of benefits and rating structures indicates smart risk management strategies to control health care costs for members.

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A Game Changer In Health Care Financing?

August 23rd, 2020

Effective September 1, 2020 we are trying out something new which I believe could be the future in health care financing – A cash pay centric plan coupled with a PCP referral process to the highest quality providers with the best medical outcomes.

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Will Texas Force Rebels Back To The Dungeon?

August 22nd, 2020

Will the TRS ActiveCare trustees act to stop the TRS ActiveCare rebellion? They better think this through because it would be political suicide to take away competitive benefits and force members back to the TRS ActiveCare dungeon. 

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Managing Risk vs Servicing Risk – The End of Status Quo Brokers?

August 22nd, 2020

With little formal training, a majority of health insurance brokers back in the day were simply spreadsheet artists………………………….

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Today’s Pharma News

August 20th, 2020

Drug prices keep going up, and up, and up with no end in sight. Isn’t it about time plan sponsors get away from open formularies and change the way they purchase drugs? Or do plan sponsors want to continue to spend and spend and spend,  more and more?

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Schuessler Stirs Up Florida!

August 17th, 2020

Psst…GodFather, Carl’s At It Again!

We just received word that Florida Schuessler Stick (The Schuessler Stick™) sales have recently spiked straining manufacturing capacity at plants world wide. So staff set out to find out why. The following is their report…………….

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A Medical Plan Whose Time Has Come

August 15th, 2020

Common sense dictates that medical caregivers who accept Medicare pricing should have no problem accepting Reference Based Pricing plans that uses the same pricing.

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Major Ruling Against Hospital Affiliated Clinics

August 15th, 2020

ANGRY HOSPITAL ADMINISTRATOR REACTS TO THE NEWS……………

“The goal of the rule is to reduce a disparity in Medicare payments where hospital-affiliated clinics get paid more than physician offices for the same services. Some critics have said the gap has helped fuel a race towards hospital-physician consolidation.”

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Lisa’s Plan

August 14th, 2020

  • Cash Pay Community Provider Network includes PCP office visits, Specialist Visits, Radiology, etc. Zero balance billing issues – Providers paid in full through electronic fund transfer at POS
  • Centers of Excellence for Surgical Procedures. Zero balance billing issues
  • Reference Based Pricing for all other services. Plan will attempt to resolve balance billing issues however there is no guarantee those efforts will always be successful

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Mulebriar Undercover Work Exposes Unusual Risk Management Strategy

August 10th, 2020

Micro-Dot Image of Heretofore Secret Health Care Strategium 

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Cigna Sued for RICO Violations

August 8th, 2020

Court records allege Cigna uses four distinct schemes to embezzle and convert funds by defrauding patients, healthcare providers, and their own Self-Insured Health Plan clients …………………

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A Day in My Life as a Physician

August 6th, 2020

So guys, this is what my typical day looks like now………………………….

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What Does Simone and The Tyler Rose Have in Common?

August 6th, 2020

“What medical school did Zuckerberg go to?”……………………………….

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Patient Thicket

August 3rd, 2020

Why price of Humira keeps rising despite FDA approval of generic competition

“Patent thicketing, and Humira is the poster child for this, builds a patent fortress around their product to protect their ability to continue their monopoly pricing.’’

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Podcast: Alternative Medical for Texas School Districts with Russ Edwards

August 1st, 2020

Here are some highlights from the podcast:

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TDI Releases Report on Balance Billing Dispute Changes

July 31st, 2020

ARTICLE REFERRED BY: Charles Luke

7/29 TDI Releases Preliminary Report on Balance Billing Dispute Changes 

The Texas Department of Insurance has released a preliminary report on the effects of recent balance billing dispute resolution procedures passed during the 86th Session in Senate Bill 1264. In the report, TDI examined 9,000 requests over the first six months of SB 1264 implementation.

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Quote of The Day

July 31st, 2020

RFQ’s for Insurance Consultants

“The problem with these outdated methods of procuring consutlants services is how many windows you have in your office is irrelevant” – Carl Schuessler

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TBX

July 31st, 2020

We know a thing or two when it comes to employee benefits. Actually we’re what you might call an “industry leader” in all aspects of online employee benefits communication, education, enrollment and administration.

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The Remarkable Purple Cow

July 30th, 2020

The Purple Cow is down in Raymondville, Texas, lonely as hell………………

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Beating Health Insurance Company Cartels

July 30th, 2020

Whether you own a company it, run it, invest or influence it- WellNet refuses to play by the rules of the ‘health insurance company cartels’ that seem to only be interested in protecting their revenue streams.

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Chargemaster Maintenance Ensures Financial Viability for Hospitals

July 30th, 2020

Hospitals are becoming increasingly proactive in updating their Charge Master’s and doing so on more than a quarterly or annual basis yet Hospitals Dismiss Significance Of Chargemaster Prices?

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Pandemic Chaos To Subside November 4 – Women Rejoice

July 29th, 2020

Gerard, our in-house prognosticator who is never wrong announced this morning that the dreaded Chinese Flu (The Pandemic) chaos will end abruptly on November 4, 2020. That’s good news for exhausted Americans.

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Puff The Magic Dragon – The TRS ActiveCare Rebellion Gains Traction

July 27th, 2020

At the stroke of midnight, August 31, 2020 as much as 5% of TRS ActiveCare membership may vanish……………

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The TRS ActiveCare Feeding Frenzy

July 26th, 2020
There is a frenzy of activity among insurance brokers, consultants, third party administrators and others towards seizing what is perceived to be a new found opportunity in selling lucrative group medical plan alternatives to the TRS ActiveCare program.

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Another Texas School District Challenges TRS ActiveCare Mandate

July 26th, 2020

Texas school district to over TRS ActiveCare alternative health plan effective September 1, 2020

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First Financial Offers Assistance in Exploring TRS ActiveCare Alternatives

July 26th, 2020

First Financial has engaged key partners in our market to provide access to the best and most immediate solutions available to Texas schools……………….

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The Affordable, Biblical Alternative to TRS ActiveCare

July 26th, 2020

TAKE COMMAND HEALTH touts cost saving alternative to TRS ActiveCare………………

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Mike Rowe Opines On Pandemic

July 25th, 2020

Mike, in a recent post, you said you’ve been to Tennessee and Georgia, giving speeches and filming for your new show. Before that, you were on the road shooting for Dirty Jobs. Is it really so important to film a television show in the midst of pandemic? Is it responsible of you to encourage this kind of behavior when infection rates are spiking? Don’t you watch the news? More and more cases every day – aren’t you concerned? – Darlene Gabon

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It Ain’t Over Until It’s Over………………

July 25th, 2020

Reference Based Pricing vendors rejoiced when a jury sided with a patient over an egregious hospital bill (Jury-sides-with-patient-in-hospital-bill-lawsuit/) But plaintiff’s attorneys were singing It Ain’t Over Til It’s Over………..

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Seasonal Flu vs The Dreaded Chinese Flu

July 24th, 2020

SOURCE: Greg Rudisill on Linkedin

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Fred Rusteberg

July 23rd, 2020

Fred Rusteberg wasn’t interested in the limelight, but he was always there to help the people of Brownsville, his beloved hometown, and he left an indelible mark in the process.

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Explaining American Health Care System To A Brit

July 22nd, 2020

A couple of weeks ago I was interviewed by someone in the U.K. for a podcast called The Jist. I spent about an hour trying to explain our crazy healthcare system to someone who’s had no firsthand experience with any of it. As you can imagine, most of what I told him sounded quite insane to him.

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Pam Demic

July 22nd, 2020

What exactly is being peddled here?

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Texas Facing $4.6 Billion Deficit

July 21st, 2020

Will Texas finally do something to fix health care for state employees and Texas educators? Fighting a $4.6 billion budget deficit can start with injecting common sense, reason and logic into how Texas funds health care………………….Or Is Texas still searching for their missing cajones? Hint: The little lady in Montana has them…………….

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Butler Benefits

July 20th, 2020

Josh Butler is a West Texan who knows how to fix health care…………

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Express Scripts Consultant News

July 20th, 2020

Shortly after posting the blog entry immediately preceding this post entry we received the following email message from Express Scripts:

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Ohio Sues Express Scripts

July 20th, 2020

“It’s no secret that PBMs have been keeping secret their prescription pricing in order to evade public scrutiny and rake in revenue,” Mr. Yost said. “I intend to shed light on their business model………”

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Obesity and Diabetes Fuel The Chinese Flu Dragoon

July 20th, 2020

“We knew that this was a time bomb because the percentage of obesity, hypertension, diabetes is so high,” said Dr. Adolfo Kaplan, a critical care physician who works with Dr. Brown at DHR Health in Edinburg, Texas. “

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Fly-By Medicine Sucks

July 19th, 2020

Patient Centered Health Care vs Conveyor Belt Health Care

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