By Molly Mulebriar

The City of Santa Fe has requested proposals for stop loss insurance for their self-funded employee health plan with a proposal deadline of February 23, 2015. However, New Mexico’s Insurance Superintendent issued a regulatory bulletin the week before the proposal deadline that effectively eliminates stop loss protection as a viable option for New Mexico employers that self-fund their employee health care coverage.

The task now before the city’s insurance consultant (AON Risk Solutions) and  third party administrator (United HealthCare – UHC) is to find stop loss insurance for the plan’s July 1 effective date. According to market experts this will be a near impossibility without divine intervention.  BUCA reps. are circling city hall anticipating the coming feast.

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Thanks to federal intervention in the health care system—Medicare, Medicaid, and the employer tax exclusion—hospitals have been able to charge whatever they want for their services, knowing that the average consumer has no idea how much he’s paying, because he’s paying mostly through taxes and other indirect means…………..

Accountable Care Organizations, whose explicit goal is to encourage hospitals to consolidate the provider industry, thereby gives them more leverage to charge higher prices…………

The U.S. hospital industry is crony capitalism at its finest

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Stop loss carriers are likely to exit the New Mexico market this year leaving self-insured medical plans without coverage.

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Independent insurance firm, Higginbotham, announced has united its three Houston offices under one roof and one operating name.

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Allstate Insurance Co. has plans to approve 20 agency offices in the San Antonio and Austin markets this year as part of a broader plan to add 130 new agency owners in Texas.

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Humana Inc. and Weight Watchers International are teaming up to provide San Antonio employers that carry Humana health insurance the ability to give their workers the option of signing up for free and discounted access to weight-management services.

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San Antonio’s IBTX Risk Services will soon begin marketing risk-management services to clients in the Bayou City with the opening of the company’s new Houston office.

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Last night, CBS Evening News aired an investigative segment about certain compounding pharmacies that have exploited industry loopholes to bill thousands of dollars for topical pain creams that don’t provide any clinical benefit.

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“To put this simply, governments don’t tax other governments,” said DeWine. “This illegal taxation is another example of federal overreach the administration’s refusal to operate within the boundaries of federalism.”

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“Account managers are like Army sergeants. A well seasoned sergeant makes sure the goals of the officer corp are reached and they only have to take an order once to get the job done. Failure is not an option……..”  

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“By the time you add third party intermediary fees of $1 million and consider the additional balance billing liability to plan participants, Cost Plus Insurance may not make much sense to those in the domino parlor.”

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National Underwriting Services, Inc., (NUS) is a Managing General Underwriter providing stop loss solutions for self-funded employers. Founded in 1985, NUS is located in the beautiful Texas Hill Country near San Antonio, Texas.

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Why did our fund balance fall so sharply last year?  And why is it still declining?  Our decline in fund balance is primarily due to our self-funded health insurance program, which is simply not sustainable as presently designed.

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February 20, 2015

Wisconsin Gov. Scott Walker is proposing that state employees be offered $2,000 a year to opt out of state health insurance coverage.

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 Beto Salinas

The 1115 Waiver is a federal program meant to provide incentives to taxpayers to become more dependent upon government. It takes political courage to recognize the 1115 Waiver for what it is. Mayor Beto Salinas of Mission, Texas is a rare man of courage………

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Now groups with as few as 5 employees can take advantage of self funding…….

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Entrepreneurial Spirit and the drive to do things differently

Healthcare Highways is a new, innovative health plan partnered with providers, employers, payers and other strategic business relationships to develop and offer a real choice in the delivery of healthcare.

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Orein Risk Analysts, Inc., has a unique stop loss insurance product that provides plan sponsors with the ability to budget for future expenses with stop loss terms locked in over a three year period.

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Health Insurance Broker Contemplates Future

ACA Allows States to Open Exchange To Big Employers in 2017.

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Guthrie also said that the legislature would have to change the law to allow districts to opt out of ActiveCare, which TSTA supports.

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The Harlandale ISD board of trustees will discuss Tuesday whether to have outside law enforcement agencies investigate former board president Velma Ybarra for possible violations of state procurement laws.

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 Mike Dendy

No one will bring down America’s highest-in-the-world health-care prices until consumers and the employers who pay for most privately financed care know what the prices actually are, says Mike Dendy, CEO of Atlanta-based Advanced Medical Pricing Solutions. Americans not only pay the world’s highest prices for care, but what they pay varies wildly from doctor to doctor, hospital to hospital.

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 What! A $10 co-pay!

“Why are patients paying more for health care?  It’s the drug prices…….increasing 13% last year alone…”

ObamaCare Solution: Bronze Plan $6000 deductible with no first dollar coverage. Rx covered after satisfaction of deductible, and is a reimbursement benefit to the insured (insured pays for Rx with cash, then files claim like in the old days…..)  A patient who must pay cash up front before reimbursement will be a better consumer with skin in the game instead of an entitlement zombie who could care less about what costs are other than that egregious $10 co-pay.

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“CMS: Meaningful Use penalties to reach $200M – Current CMS data indicate that eligible professionals are facing an estimated $200 million in Medicare reimbursement penalties in 2015 for failure to fulfill Medicare meaningful use obligations. The numbers were announced this week during a HIT Policy Committee meeting.” By Heather Caspi, February 13, 2015. (more).

http://www.healthcaredive.com/news/cms-meaningful-use-penalties-to-reach-200m/363963/

Regardless whether the eligible professionals deserve the claw-back penalties or not, the important lesson here is: Do everything you can to avoid doing business with the U.S. government, Doc. They will own you.

Dr. Pruitt – darrelldk2@gmail.com

“My friend, Trent, is an auto mechanic. When he was growing up, he loved to work on old cars. He rebuilt his first one when he was fourteen — and drove it for 11 years. He loved finding problems and figuring out how to fix them. He never cared about getting rich; his goal was to make a decent living doing something he loves, and his dream had always been to open his own garage.”

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“The problem with socialism is that you eventually run out of other peoples’ money.” – Margaret Thatcher

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Second Acquisition in Three Months for New Employer Healthcare Benefits Platform

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Obamacare’s startup health insurance plans are flirting with financial distress, as all but five of the 23 nonprofit companies had negative cash flow from operations in the first three quarters of 2014, Standard & Poor’s said in a report today.

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“…..when I hear large corporations that make billions of dollars in profits trying to blame our interest in providing health insurance as an excuse for cutting back workers’ wages, shame on them,” Obama”

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Patrict Carrier, CEO Christus Santa Rosa

“Christus Health, which operates hospitals in several Texas cities and in Louisiana, New Mexico, Chile and Mexico, is reducing the number of its domestic operating units from eight to three. Carrier said the changes will streamline and simplify Christus’ regional operations and expedite the decision-making process across all affected markets. He will divide his time between both markets.”

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 Adam Russo

From its simple beginnings in my mother’s basement to our current status as an industry leader, even I, confident as I was that we’d succeed, am shocked and grateful for the level of success we’ve achieved together.

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 Surplus Lines Agent

“To say the move both surprised and shocked the state’s wholesale insurance broker community would be an understatement.”

“Few were willing to speak publicly about it. However, off the record many members of the Texas MGA community expressed frustration and confusion — in some cases disgust — that the largest state affiliate of the Big “I” would go into direct competition with them in the wholesale insurance marketplace.”

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Update on previous post: ADMINISTRATION IGNORES BOARD, AWARDS $3.3 MILLION INSURANCE TO SAME VENDOR, CONSULTANT

Vendor writes complaint letter to BISD – Klement Letter

“This is the kind of stuff that the FBI is looking for,” said a BISD administrator. ”

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   ER at Bull Run

“As I speak to folks in my district, I regularly hear stories of confusion regarding the difference between urgent care clinics and these freestanding emergency rooms, which are generally far more expensive,” the Republican from Georgetown said.

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Aetna is now offering a fully insured Aetna Whole Health℠product for Baylor Scott & White Quality Alliance in the greater Dallas-Fort Worth area and Seton Health Alliance in the Austin area.

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Chicago-based Hub International Limited (Hub), has acquired Alexander Insurance Agency (Alexander), headquartered in San Antonio, Texas.

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This five word sentence caused a $1 million fine:  “The Patient was a smoker”

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Consumers have an increasing amount of “skin in the game” when it comes to medical and financial decisions for their care, and their interest to access credible information and user-friendly tools and resources about cost and quality is growing.

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HOUSTON (January 23, 2015) Ascende just completed renegotiations with pharmacy benefit managers (PBMs) that dramatically improve guaranteed pricing agreements for the company’s pharmacy purchasing collective. This is expected to significantly reduce employers’ pharmacy costs in 2015 and result in a lower year-over-year trend

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The “new” payment model for healthcare providers is actually as old as feudalism.

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According to yesterday’s article in the Brownsville Herald, 790,245 Texans are on health insurance welfare rolls (84% receive welfare, i.e, subsidies). Another 128,645 Texans are on health plans too but those poor bastards are not getting any type of welfare assistance (subsidies) at all. That’s unfair!

The article points out that there are approximately 6 million uninsured Texans. So that must mean that there were about 7 million uninsured Texans but now that 918,890 have become insured under ACA that leaves only 6 million left to sign up (80 signed up yesterday in Brownsville according to the article).

Are the 5,999,920 million left to sign up non US citizens? If so, then there are no uninsured Texans according to ACA rules.

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“Since the mid-1980s, hospitals and physicians have billed commercially insured patients extra to cover their losses on Medicare, Medicaid and uninsured patients…….”

But  “Losses” may only mean “less money” and not necessarily negative cash flow. If Medicare pays $10 for a service, and private payers pay $12 for the same service, one could claim the provider “lost” $2 on Medicare patients. Semantics is a powerful tool.

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In 2011, federal officials estimated about 40 percent of the new PPACA CO-OPs they were helping to start would eventually fail.

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 Rina Tikia

The Louisiana Board of Ethics has charged the Lafayette school board’s former insurance consultant with violating ethics laws by offering a school board member tickets to a New Orleans Saints game while “seeking a contractual and business relationship” with the school board.

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“ADP will provide a Health Care Premium Guarantee for you and your employees from 1/1/2015 to 6/1/2016, so you know for the next 18 months that your renewal will not be higher than 12%. “

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AMPS is looking to add two top tier sales professionals to help us with the incredible demand for our Reference Based Reimbursement (RBR) solution. Do you want to continue to sell sugar water or come with us and change the self insured world? We love what we do, it’s all we do and no one does it better. If you want to LOVE what you do too, contact John Powers at jpowers@less advancedpricing.com or 630.361.2525

“This is what happens when you put Marxists in charge of making these decisions.”

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“This thing has really gotten uglier and uglier and uglier,” said attorney William Gast, who represents the Fulkerson family and Countrywide Insurance Agency.

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“The Administration’s “historic” announcement on Monday marks “the first time the government has ever set specific goals to steer the nation away from fee-for-service payments.”

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Amazing Revelation! Will Coke Cola Recipe Be Next? 

There’s a fascinating story out of North Carolina about that state’s largest insurer unexpectedly publishing information on how much it pays healthcare providers for a wide range of elective, non-emergency services. ……Such payments normally are closely guarded business secrets……………………Providers were not pleased.

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“Just give me a quote along with the other five agents I have contacted. Never mind that my current agent has that information!”

“As I’ve aged and acquired more experience and am blessed with the knowledge that dinner is on the table whether or not I make a sale today, I’ve become more stubborn about insisting that if a prospect wants my involvement and engagement in seeking coverage, then they have to co-operate at minimum levels…………”

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January 21, 2015, San Antonio, TX — A former deputy U.S. Marshal and Mission police officer pleaded guilty Wednesday to federal fraud charges after he falsified insurance documents and forged a doctor’s signature, prosecutors say.

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“Steve Jobs chose to be listed for a liver transplant in Tennessee rather than where he lived in Northern California, which has an average waiting time 6 years, because he was more likely to get a new liver in Memphis, which has an average waiting time of 3 months.”

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Frustrated by the lack of simplified hospital quality information, MPIRICA’s founding team are healthcare consumers like you, who just happen to also be tech entrepreneurs.

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By David Belk, M.D.

A number of generic medications have skyrocketed in price recently and quite a few people have asked me about it. In order to comprehensively address this problem (or at least define it) I did a survey of what pharmacies in the US have paid for 1,240 listings (including different doses and preparations) of over 400 generic prescription medications each quarter from October 4, 2012 through January 7, 2015). I tracked how the price of each listing changed each quarter and in total.

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By Molly Mulebriar

We like the simplicity of the offer. It’s refreshing and a good starting point……………..But a 50% discount off an inflated number can be anything you want it to be and 315% of Medicare seems a little outrageous……………..

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BROWNSVILLE – A jury on Wednesday found a Brownsville resident guilty of securities fraud and theft.

Prosecutors said Alberto Alba Villarreal, 45, sold a bogus $1 million investment contract in Nafta Holdings LLC, to help fund a new insurance company. The fraud happened in November, 2008.

Officials said Alba Villarreal instead spent the money in less than three months on personal expenses and lavish purchases.

A jury sentenced Alba Villarreal to 10 years community service and was ordered to pay $10,000 for the securities fraud. He was sentenced 5 years in prison and ordered to pay a $10,000 for the theft count.

Visiting Judge Federico Hinojosa ordered Alba Villarreal to pay $1 million in restitution to the victim.

http://m.krgv.com/news/Brownsville-Man-Sentenced-in-Securities-Fraud-Theft-Case/30759242

See: Funding New Texas Insurance Company Proves Problematic

RFP #2015-02 – Insurance Benefits Consulting Services. This bid is scheduled to close on Feb 5, 2015 4:00:00 PM CST

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PAMELA WIBLE, MD | PHYSICIAN | AUGUST 7, 2014

I love caring for patients — young and old. And though I may not accept your insurance, I will always accept you. I’m still happy to care for Medicare patients even though I opted out of Medicare in 2006. Why don’t I accept Medicare? Let me fill you in.

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“If were alive today, he would support the revival of labor unions in general and professional labor unions in particular.”

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PETER UBEL, MD | MEDS | JANUARY 12, 2015

India is not, yet, a wealthy country. Nevertheless its people experience many of the same expensive-to-treat illnesses as wealthier populations in the U.S. and Europe. Therefore, the country has made a series of policy decisions designed to lower the cost of medical treatments.

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Plan to attend if you are a compliance professional from a health plan (all levels from officers to consultant), in-house or external counsel for a health plan, an internal auditor from a health plan, regulatory compliance personnel, or a managed care lawyer.

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