Working The Spread

October 23rd, 2017

The Weslaco ISD lawsuit against Aetna is a fascinating read. The pleadings provide clues for those who are curious about various revenue streams found (or not found) within some administrative contracts for third party administration of group medical plans.

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Getting Screwed

October 23rd, 2017

When it comes to hospital bills, you don’t get the itemized version of the bill, so you often have no idea what you are actually paying for………. Read the rest of this entry »

EDMUNDO O. RAMIREZ  – 1952-2017

October 21st, 2017

Edmundo was a fighter. He fought hard for his clients and protected those he loved. He lived life on his own terms, and he died on his own terms. This rock solid, self-made man will be missed by many. 

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Slapped In Texas

October 20th, 2017

TPA Loses Lawsuit Against Private Citizen

“The Texas Legislature unanimously adopted one of the strongest Anti-SLAPP statutes in the nation and showed their continued support of the First Amendment.  On June 17, 2011, the Texas Citizens Participation Act (the “Texas Anti-SLAPP statute”) was signed into law by Gov. Rick Perry.”

“The statue allows a judge to dismiss frivolous lawsuits filed against one who speaks out about a “matter of public concern” within the first 60 days.  “Matter of public concern” is defined expansively in the statute.” (slappedintexas.com/primer/)

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Pile Makes Incredible Offer

October 19th, 2017

“I’ll Make You An Offer You Can’t Refuse”

Can anybody use 5% of their healthcare spend back?? Give me a call so I can show you why there is 5% there and how we will find and recover it for you.

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Direct Pay (Cash Pay) Strategies Make Sense

October 19th, 2017

By Bill Rusteberg

Direct Pay strategies, which I call Cash Pay strategies, has had a positive impact on a 400 life case we manage.

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Open Enrollment as Turd Polishing Season is Over

October 18th, 2017

For 20+ years, Open Enrollment has meant explaining to employees how they’re going to pay more and get less when it comes to health benefits……………………..

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TPA Promotes Reference Based Pricing Model – Guarantees No Balance Billing

October 18th, 2017

A TPA specializing in self-funding for small group plans of 100 employee lives or less offers a unique Reference Based Pricing model that includes the promise of no balance billing.

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Opioid Crisis Fueled By Drug Industry and Congress

October 16th, 2017

Whistleblower Joe Rannazzisi says drug distributors pumped opioids into U.S. communities — knowing that people were dying — and says industry lobbyists and Congress derailed the DEA’s efforts to stop it

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Insurance Consultants Are Biased

October 16th, 2017

mulebriar

“The last category of independent insurance consultants are those that are never comfortable outside their insulated environment. They like the warm and fuzzy feeling of staying at home in a loving environment with Mommy.”

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Largest Employer South of San Antonio Seeks Insurance Consultant

October 15th, 2017

Brownsville Independent School District, the largest employer south of San Antonio, Texas is seeking an insurance consultant for the district’s self-funded employee health & welfare plan.

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Selecting a Third Party Administrator

October 12th, 2017

By William Rusteberg

Selection of a third party administrator (TPA) is crucial to the success of a self-funded plan. Criteria usually revolve around several factors including compatibility. Corporate philosophies of the employer and TPA should harmonize.

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The Cost of Convenience

October 12th, 2017

ppoo

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Express Scripts to acquire EviCore Healthcare for $3.6

October 10th, 2017

Pharmacy benefit manger Express Scripts will acquire medical benefits management company eviCore Healthcare for $3.6 billion, which will give the company an entry point into a growing market, the company announced Tuesday in a securities filing.

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Dendy Opines

October 10th, 2017

When people or companies live off of opacity, there is a problem as one never knows if they are being treated fairly or not” – Mike Dendy

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How One Of America’s Most Innovative Benefits Leaders Reduces Clients’ Healthcare Spending 20%

October 9th, 2017

David Conterno

When the industry goes to higher deductibles, we remove them. When the industry goes to narrow networks, we remove networks. When the industry goes to narrow formularies, we expand them. When the industry invests in specialty care and surgical centers, we invest in primary care. When the industry looks to bring in more insurance products, we bring in less. Instead of increasing obstacles to getting any and all care, we need to be removing all obstacles to getting the right care.”

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Risk Tolerance & Reference Based Pricing Strategies

October 8th, 2017

By Bill Rusteberg

Plan sponsors must recognize change brings risk and reward and understand doing nothing brings risk too. So what’s the difference?

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Over 1/2 Of New Cancer Drugs Show No Benefit For Survival or Wellbeing

October 7th, 2017

Of 48 cancer drugs approved between 2009-2013, 57% of uses showed no benefits and some benefits were ‘clinically meaningless’, says BMJ study…………………

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Is All Preventive Care Screening Cost Effective & Prolong Life?

October 7th, 2017

Physician Joins Witness Protection Program?

“We knew for years that if a patient is a smoker the risk of lung cancer is high.   So why did we not have annual chest x-ray as a screening tool? ” (Name Withheld) M.D.

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4 Texas Hospitals Pay $8.6 Million Over Kickback Allegations

October 6th, 2017

“Why Didn’t I Think of This!

Bernie Madoff

“If not for this kickback arrangement, the four hospitals would have been financially responsible for the patient transports at significantly higher rates………………..”

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How 2 Math Grads are Disrupting the Auto Insurance Industry

October 6th, 2017

Insurance industry continues to be rocked by innovative upstarts. This time disruption is not confined to health care, it is encroaching upon the property & casualty industry too…………..

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Association Health Plans: A Favorite GOP Approach To Coverage Poised For Comeback

October 6th, 2017

Under association health plans, small businesses can join associations — based on certain types of professional, trade or interest groups — that offer insurance to members.

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America Is Surprisingly Reliant on Foreign Medical Graduates

October 6th, 2017

Recent Foreign Medical Graduates Seek Internship in USA

By any objective standard, the United States trains far too few physicians to care for all the patients who need them. We rank toward the bottom of developed nations with respect to medical graduates per population………………….

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Trump Set To Roll Back Birth Control Mandate

October 6th, 2017

The Trump administration is poised to roll back the federal requirement for employers to include birth control coverage in their health insurance plans, vastly expanding exemptions for those that cite moral or religious objections……………….

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Moonbeam Ponders Signing Drug Transparency Bill

October 6th, 2017

“If it gets signed by this governor, it’s going to send shock waves throughout the country…..”

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Employer’s Health Care Congress 2017

October 5th, 2017

Jeff Bernhard, President of Continental Benefits

This revolution is happening faster than I would have ever thought.  If you are a consultant and not sharing creative TPA options at this time, you will likely lose to a competitor consultant.”

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Self-Insurance Plan Could Save Idaho $13M, Consultant Says

October 5th, 2017

A new analysis on how much Idaho would save by switching public employees to a self-insurance model puts the amount at $13 million for the first year of operation……….

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Health Care Networks of America – Restoring Physician Prosperity!

October 3rd, 2017

“Don’t Miss 70% – 85% of Billed Charge Reimbursement Rates!” touts Health Care Networks of America (HNA).

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October 2nd, 2017

RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.

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Unique Defined Contribution Plan for Voluntary Benefits

October 2nd, 2017

What if a plan existed where employees could get what they wanted regardless of their health status and regardless of group participation requirements?

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Employer Healthcare & Benefits Congress

October 2nd, 2017

The Employer Healthcare & Benefits Congress (EHBC) brings together attendees from across the world to discuss the latest developments in employee benefits industry, from corporate health & well-being programs and the latest in healthcare reform, to trends in voluntary benefits and self funded insurance, the EHBC has the information you need.

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More States Looking to Section 1332 Waivers

October 1st, 2017

States can apply for a federal waiver “to implement innovative ways to provide access to quality healthcare……” Does that include Reference Based Pricing strategies?

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The Monty Hall Problem

October 1st, 2017

The Monty Hall Problem is an interesting study of Probility & Combinatorics. Actuaries among us will enjoy this short video………………………

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Who Starts Tyrone’s Car In The Morning?

September 30th, 2017
Pssst………..Tyrone Is At It Again Godfather!

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Blue Cross Blue Shield of Texas Validates Reference Based Pricing Strategies

September 30th, 2017

Blue Cross has successfully hijacked the term Reference Based Pricing  –  a damn smart marketing move……………………

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Balance Billing Is A Plan Sponsor’s Best Friend

September 28th, 2017

jet

By Bill Rusteberg

“Balance billing only occurs when purchasing  goods or services without asking  the price.”

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Article Reveals More Than Headline

September 28th, 2017

“The provider network is probably the biggest thing we think about,” said Kristine Grow, a spokeswoman for the industry group America’s Health Insurance Plans…………

Editor’s Note: This article is entitled one thing, but moves down multiple rabbit trails. The quote above for example illustrates the status quo mindset of many Americans mired in the quicksand of PPO networks. Then the article goes into “subsidies” which of course is just a politically correct word for welfare, or Americans on the dole. It seems to this reader the intended thrust of the article is focused on welfare payments to offset the cost of health insurance…………..Another massive transfer of wealth and America’s continuing  move towards socialism………….

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TRS Feeding Frenzy in Full Swing

September 27th, 2017

Over the past few months I have been telling you about the TRS Care health and drug plan changes coming 1-1-18.

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Hospital Costs Flat – But Plan Sponsors Don’t Benefit

September 27th, 2017


Michael (Mike) DendyCEO/Vice Chairman AMPS Inc.2h

Hospitals are charging 5, 6, 7 times more than they were charging ten years ago. This drastic increase in billed charges must be at least partially due to hospitals’ cost of doing business increasing, right? Wrong.

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ObamaCare Endures – Big Government Wins

September 27th, 2017

A dysfunctional Republican party breaks promise to repeal ObamaCare.

Tight government control and oversight of 1/5 th of the economy continues. Citizens will continue to be punished if they refuse to purchase health insurance……………….Individual freedom is eroding away bit by bit in this country.

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Medical Trend

September 26th, 2017

By Bill Rusteberg

Medical trend (inflation) is largely due to inflated medical costs guaranteed to increase year after year in managed care contracts through annual escalator clauses (Escalator Clauses, Rising Prices, And Why We Should Care). In addition, renegotiated contracts effectively cause a double whammy (renegotiated provider contracts always end up costing more, not less).

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Latest So Called “Repeal Bill” Cuts Off All ACA Funding After 2026

September 25th, 2017

A dysfunctional Republican party has yet another “Repeal” bill that contains provisions likely to be repealed (again) over time as the unified, “take no prisoners” Democrats gear up to win back the House in next year’s mid-term elections…………………..This newest feeble version maintains the government’s control of 1/5 th of the American economy and gives more power to bureaucrats…………

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Amazing Stop Loss Insurance Statistics

September 24th, 2017

Kaiser Family Foundation Employer Health Benefits Survey on stop loss insurance highlights some interesting statistics…………..

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Got You Covered

September 23rd, 2017

Do you have fan belt insurance? How about flat tire insurance?

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Sullivan Appointed as Texas Insurance Commissioner

September 23rd, 2017

Texas has a new insurance commissioner………………………..

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Health Insurers in New Mexico To Implement Record-High Premium Increases

September 23rd, 2017

Insurance superintendent says premiums are spiking because not enough people are signing up for coverage……………Or are the actuaries incompetent?

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Amazon In Talks With PBMs

September 21st, 2017

A threat to the pharmaceutical industry………..?

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The Big Heist

September 21st, 2017

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Pfizer Sues Johnson & Johnson Alleging Anticompetitive Practices

September 21st, 2017

What Consumers Can’t See Will Hurt Them

If Pfizer is successful, it could discourage brand name companies from using deals with insurers to limit competition

Editor’s Note: Plan sponsors have no idea how the economics of our health care delivery system are birthed behind closed doors between third party intermediaries (carriers, PBM’s, etc) collaborating with one another………………….It’s all about the money and nothing about consumers………..

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Blue Cross Against ObamaCare Repeal Bill

September 21st, 2017

“The bill contains provisions that would allow states to waive key consumer protections……”

Editor’s Note: Why is BCBS against the latest attempt to repeal ObamaCare? Could it be that onerous mandates that drive costs up leads to higher premium costs resulting in higher carrier profits through application of the Minimum Loss Ratio government requirement? If a carrier is required to return 80 cents on the dollar in benefits, the higher the cost the more income the remaining 20% produces to the benefit of the carrier’s bottom line. Carriers these days are breaking financial performance records in valuation growth………………..

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Study: Changing Carriers = Higher Utilization?

September 21st, 2017

These average utilization changes reflected larger changes in use shortly after the insurance switch that diminished over the subsequent year………………..

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“Healthcare Tax” To Push Businesses Away From Your Community?

September 20th, 2017

IBM recently made a decision as to where to locate 4,000 new hires based on their analysis of where they received the best value from their healthcare expenditure. Consequently, they determined that Dubuque, Iowa was the best location to expand their employment.

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Fake-A-Disease Brings In $11,000 For Texas Man

September 18th, 2017

Texas grand jury indicts ex-teacher’s aide who faked cancer………….

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Healthcare Is A Right While Water is a Must

September 18th, 2017

If water is a must and healthcare is a right how does one distinguish between the two?

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PPO “Discounts” Mean Nothing – Only Dummies Remain Enamored

September 18th, 2017

My Discounts Are Better Than Yours Because My Boss Told Me So

“As we all know discounts are really no longer a relevant method in determining whether a network is “good” or not” – Jeff Bernhard

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Unpacking The Bernie Bongo Medicare-For-All Bill

September 18th, 2017

The Bernie Bongo Senate Bill, unlike the ACA, is only 96 pages long……………………

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A Billion Here, A Billion There: Selectively Disclosing Actual Generic Drug Prices Would Save Real Money

September 18th, 2017

Because pharmacies, not generic manufacturers, are “where the money is,” the opportunity for savings comes from reducing reimbursement to pharmacies for generic drugs. In the case of generic drugs, potential savings could exceed 10 percent………………………

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Hospitals Oppose ObamaCare Repeal

September 18th, 2017

America’s Essential Hospitals announced its opposition to a new ObamaCare repeal and replace bill, warning of cuts and coverage losses…………………

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Does Your Plan Do This?

September 15th, 2017

Medical Bill Review

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Medicare Benefits For All – The Bernie Bongo Plan

September 15th, 2017

By Molly Mulebriar

There is a lot of talk these days about “Medicare For All.” If this is such a good idea, and will “solve” the nation’s broken health care delivery system, why not change your current employee benefit health plan to mirror Medicare benefits and payment schedules?

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Another ACA Lie – Preventative Care Actually Does Not Save Money

September 15th, 2017

As counterintuitive as it seems, preventive measures generally increase rather than decrease costs……

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Obsession With Genitals Leads To Termination

September 15th, 2017

Two doctors have been suspended and a director ousted after hospital staff piled into an operating room to gawp at an unconscious patient with an object in their genitals…..

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Get Ready! Medicare Will Mail New Cards to 60 Million People

September 15th, 2017

Medicare is getting ready to issue all 60 million of its beneficiaries new cards with new ID numbers as way to combat identity theft and fraud…………..

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Investing In The Cartel Can Be Lucrative

September 14th, 2017

The Cartel is at it again…..

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School District Suspends Changes To Healthcare Plan

September 13th, 2017

About 20 employees (less than 1% of the district’s work force) has succeeded in getting the largest employer south of San Antonio to suspend a scheduled increase in members costs towards the district’s self-funded employee health plan.

Perhaps the next step is to get these 20 or so employees to picket and protest outside the community’s two hospital systems against egregious costs. That $1,000 toothbrush charged by some hospitals could be their first bargaining chip…………………….

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Local Brownsville, Texas Blog Provides Better Coverage Than Mainstream Media

September 12th, 2017

TEACHERS, BISD EMPLOYEES AGAINST HEALTH INSURANCE HIKE

(Compare this blog article to the posting immediately blow this post…………

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Front Page News – 20 Employees Out of +8,000 Complain of Health Care Cost Increase

September 12th, 2017

A small group of 20 employees of the largest employer south of San Antonio, Texas, or about .0025% of the entire labor force, receives front page news over health insurance cost increase protest. The other +8,000 employees remain silent………………….. 

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Independent Consultants Declare Old Model Fails Customers

September 12th, 2017

This summer — and at Independence Hall in Philadelphia, no less — a group of 30 benefits consultants signed their own “declaration” outlining a novel strategy based on collaboration over competition.

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How Do We Hold A PBM Accountable?

September 12th, 2017

How do we hold a PBM accountable who selects a poorer drug with weaker outcomes and higher risk?

Plan sponsors get screwed even worse than they know………………

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Why One California County Went Surgery Shopping

September 11th, 2017

Frustration with sky-high hospital bills and a lack of local competition is common to many employers and consumers across the country……….Fed up with wildly different price tags for routine operations, some private employers are steering patients to top-performing providers who offer bargain prices.

Santa Barbara County, with about 4,000 employees, is among a handful of public entities to join them.

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Trump To Support Medicare For All?

September 11th, 2017

Demoralized Republican Majority Leaders Sulk

Will Trump support the Democrat’s Medicare For All proposal next week? The do-nothing Republicans have been a huge disappointment to Trump supporters. Last week, signalling his frustration with lying Republican politicians, Trump joined with the Democrats in getting the debt limit extended.

Will Trump join Democrats in calling for a single payer system? Perhaps so. There are just too many political positives in doing so. Trump can point to the disfunctional health care system and basically say “Enough is enough! We need to get this past us. No one in the health care delivery system wants to fix it, so government will have to fix it! It’s time we put this to bed and start concentrating on creating new jobs, lower taxes, and make America Great Again…………………..

With 48 Democrats in the Senate, Trump needs only two Republicans to support a single payer system. That should be no problem at all………………….

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CEO’s Guide To Restoring The American Dream

September 10th, 2017

JUST RELEASED: A must read book by Dave Chase

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TDI Releases Report On PPO Out-of-Network Payments

September 7th, 2017

The Texas Department of Insurance today released the results of a survey that looked at out-of-network payments by preferred provider organizations (PPOs) for certain services. The survey found that most plans comply with the state requirement to pay such claims “at the usual or customary charge for the service.”

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A Texas Public Purchasing Lesson – RGV Vending vs Weslaco ISD

September 6th, 2017

“RGV brought this action, claiming that the Board’s action violated section 44.031(b) of the Texas Education Code. Particularly, RGV complains that the Board failed to consider the criteria listed in section 44.031(b);  it believes that consideration of those criteria conclusively establishes that its bid was superior to the accepted bid…………..WISD’s failure to comply with section 44.031(b) provides a basis for RGV to raise its complaints in a court without first exhausting its administrative remedies.   Therefore, the trial court erred in granting WISD’s plea to the jurisdiction. ” Appellate Court Opinion

A Request for Proposal evaluation process includes criteria upon which points are assessed in the evaluation process. Failure to comply with the formal evaluation process can lead to vendor protests…………

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Lowering Costs & Getting Paid More Makes Sense

September 6th, 2017

“I had a client actually offer to pay me even more because of the value I was delivering………….” – David Contorno

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