How To Field Rate Any Insurance Risk

January 20th, 2022

A student accident insurance company underwriter once confided to me how he rates his renewals. “It’s easy peasy” he said.

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TRS ActiveCare Under Siege

January 20th, 2022

Regional service centers have now been effectively placed in a position where they must make a recommendation to the state as to whether a commercial health plan alternative is better for member districts than the TRS ActiveCare government plan.

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California Poised To Pass Single Payer Reference Based Pricing Plan

January 19th, 2022

California Hospital Administrator Reacts

The bill would eliminate commercial health insurance and Medicaid coverage in California and replace those forms of coverage with CalCare, a government-run health plan that will pay medical care givers 100% of Medicare allowed charges………………..

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But Hank Said……………………

January 18th, 2022

Henry  “Hank” Miltenberger

“When you go public, it changes the culture. That can be good for some companies, but we’re glad we don’t have to worry about quarterly earnings reports. I’ve never considered selling Gilsbar. I don’t view the business as a investment. It’s a stewardship. I hope to hand it off to someone with the same values—values where people are a priority over dollars.” (Up With People – New Orleans Living Magazine)

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Albert

January 13th, 2022

I saw this photo on Linkedin this morning and it reminded me of Albert, a South Texas native with one of the biggest set of brass cojones ever recorded within the insurance industry…………..

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Network Adequacy Standards For QHPs And More Guidance For 2023

January 12th, 2022

Heath care in this country has essentially become a government regulated utility. New 2022 health care mandates are causing employers more headaches and putting them at additional risk for punishing sanctions if they fail to comply. And if you have a network plan, more regulations may be coming in 2023.

It may be time to drop your network………………..

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General Agents & Compensation Disclosure Rules

January 12th, 2022

 In instances in which the overrides are shared with brokers and consultants, even if only in the form of rewards, trips, prizes, or gifts, etc., disclosure is required based on what appears to us to be a plain reading of the rule.

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I Hate Surprises

January 10th, 2022

Plan Sponsor Gives Up – Moves Factory To China

“In a world where payers will be forced to pay more, and providers are not punished for charging excessive amounts, there is no downside to charging more, ignoring negotiations, and waiting for arbitration.” – Ron Peck

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What Plans & Services Are Impacted by NSA

January 10th, 2022

Government Bureaucrat Memorializes Regs

The interim final rule published in July 2021 clarified that the NSA is applicable to indemnity plans, which suggests that reference-based pricing plans would also be covered by the law.

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The Rise of EPO’s

January 9th, 2022

“I never had a call that an employee had been billed for the difference for an out-of-network provider or got stuck with a big surprise bill. And that is so important because that is a fear” – EPO Plan Sponsor

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The Healthcare Industry & The U.S.S.R.

January 8th, 2022

Sometimes we lose an understanding that history and the human experience is eternal. This video gives insight tied to both. Things that are said to never change do……………

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CPAs Shift Audit Risk to Plan Fiduciaries

January 7th, 2022

SAS 136  increases the need for error-free payroll files and impeccable compliance in areas like compensation, distributions, and vendors’ fees.

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Abilene ISD Opts Out of TRS ActiveCare

January 5th, 2022

    2022 TRS ActiveCare Theme Song by Queen

“When we started looking at this … we thought this was going to be a tough decision,” Zeller said after the meeting concluded. “But when we started researching, the quality of the products out there, the caps the companies were willing to give us, a three-year cap on increases, it made it evident the market helped us make this decision.”

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Dark Horse TPA Acquires Texas School District Business

January 4th, 2022

Out of the blue a dark horse out-of-state TPA captures Texas school business from right under the noses of Texas based TPA’s vying for the same business……….Region 14 Education Service Center, Abilene Independent School District, Crowley Independent School District, and Pearland Independent School District…………….

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A Health Insurance Company You Never Heard Of

January 4th, 2022

Two guys in Colorado started Friday Health Plans six years ago and have now expanded into Texas…………………

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The Telehealth Bubble Has Burst

January 4th, 2022

The telehealth bubble has burst. Time to figure out what’s next

Telehealth took off during the pandemic, but 2021 was a brutal awakening. The healthcare industry is still figuring out how it fits into the big picture.

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Group Health Insurance Is Not What It Used To Be

January 3rd, 2022

Plan Sponsor Reacts To Sales Pitch

A 500 life case is in the process of renewing their group health insurance plan. Their claims are running hot.

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Millions More Patients in Washington Could Soon Have Access to Charity Care

December 28th, 2021

Article Referred by Doug Aldeen

December 15, 2021 at 11:02 am PSTBy Jesse Jones, KIRO 7 News

OLYMPIA, Wash. — Charity care is a necessity for families all over the state and hospitals have written off hundreds of millions of dollars of care to those in need, keeping them from suffering crushing medical debt.

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Milking The System

December 28th, 2021
SOURCE: Linkedin
I used to work at a Blue Cross in the contracting department making fee schedules. When I saw the creative billings and code-shifting I thought “those dirty doctors. they’re printing money”.

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Industry Trade Groups Beg Government To Intervene In Health Care

December 27th, 2021

Industry trade groups believe big government can solve health care because they can’t.  They are begging for help. There is a way the private sector can solve health care but plan sponsors would have to break the law in order to do so. So we need more laws………… Read the rest of this entry »

December 27th, 2021

Risk Strategies – A National Insurance Brokers/Risk Management Firm

December 27th, 2021

Risk Strategies (www.risk-strategies.com) is a specialty national insurance brokerage and risk management firm offering comprehensive risk management advice and insurance and reinsurance placement for property & casualty, and employee benefits risks.

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December 24th, 2021

Is Your Health Plan Hospital Controlled?

December 21st, 2021

Is your plan a hospital controlled process or a plan sponsor controlled process?

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Hospital Announces They Will Reduce Their Prices

December 21st, 2021

Indiana’s largest hospital system has announced it will reduce their hospital prices. A Rand Corporation study has found that Indiana hospitals charge on average three times what Medicare does…………………”2020 Rand study found that IU Health prices between 2016-2018 ran 33% higher than the national average.”

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Grocery Chain Launches Telehealth Platform, Prescription Delivery Service

December 20th, 2021

“With the launch of this service, Hy-Vee joins the current trend of retailers investing in telehealth and remote patient monitoring technologies.”

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The Incredible Mr. Sedgewick

December 19th, 2021

By Bill Rusteberg

The 1980’s and early 1990’s were the Golden Years for brokers active in the group health insurance market.

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TRS ActiveCare To Retain A Majority of Member Districts?

December 18th, 2021

TRS Board Member Reacts To The News

For the first time in 20 years TRS ActiveCare member school districts may leave the government health plan provided they give notice of intent to leave by December 31, 2021.

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“The Doctor Will See You In One Minute”

December 18th, 2021

“Using Amazon Care, we were able to connect with a clinician in under a minute who provided medical advice that helped us get through the night. She also prescribed a medication that was delivered to our doorstep by 9 a.m. the next day”

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The 100% Freedom Health Plan

December 18th, 2021

This health plan is an expense account funded by your employer.

“When you go out of town on company business and have to stay overnight we will pay for your hotel room. The expense account limit is $150 per night so if you decide to stay at the Ritz Gold Star Hotel you will have to pay the difference” explains Sally in accounting.

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Culling Your Client Base By Earning More

December 17th, 2021

Earning more while working less is smart business………………..

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U.S. House of Representatives Releases Drug Pricing Investigation Report

December 16th, 2021
“What the Committee has learned should be troubling to lawmakers, taxpayers, and any American who has ever struggled to afford their prescriptions.”

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School District Learns Health Care Costs Tied To PPO Contracts

December 15th, 2021

It’s all about the margin………………………….

A Texas school district was interested in learning why their health insurance costs increased dramatically when they changed their plan administration from Blue Cross to an independent TPA.

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Virtual Primary Care Statistics – Mercer

December 13th, 2021

Virtual care in particular has seen a bump during the pandemic, as in-person services were limited if available at all.

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Independent Dispute Resolutions Are Not Inevitable Under No Surprises Act

December 13th, 2021

Under the NO SURPRISES ACT if there is a payment dispute (balance billing) from a provider, the health plan is required to participate in a third-party, unbiased arbitration process to establish a qualifying payment amount (QPA) for similar services in a geographic area.

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72% of HR Professionals Considering Switching TPAs

December 13th, 2021

Findings are based on a survey of 600 U.S.-based HR professionals who are directly involved in managing their company’s health insurance

72% of respondents said their organization is considering switching its healthcare insurer or plan administrator in 2022 — signaling a level of dissatisfaction and disengagement across the industry.

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Texas School District Wins “Highest Cost Health Insurance” Award

December 12th, 2021

Eagle Pass Independent School District has got to be paying more for health insurance than any other school district in Texas…………………..

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No Surprises Act and Its Impact on Reference Based Pricing Plans

December 12th, 2021

SOURCE: Multiplan

This Q&A should give a degree of comfort to those worried about the impact the No Surprise Act will have on Reference Based Pricing plans. However, one must always consider the source when coming to one’s own conclusions.

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Will Reference Based Pricing Plans Survive In Their Present Form?

December 11th, 2021

By Molly Mulebriar

In one of the most far reaching edicts issued by Congress and promulgated by faceless bureaucrats in Washington, the American health care delivery system is about to enter a new era bringing fundamental change to the way health care is financed and delivered in this country.

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Texas Teachers Have Better Health Insurance Options Than TRS ActiveCare

December 10th, 2021

As the deadline approaches for Texas school districts to decide whether to continue TRS ActiveCare membership we see more competitors vying for the business.

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Mulebriar Proposes 100 Year Rate Guarantee For Texas School Districts

December 8th, 2021

Nothing like a good dose of competition these days. Now, for the first time in over 20 years, Texas school districts have government permission to exit the program. Intense, pent-up competition is hell bent on peeling off as many districts as possible from the government health plan with the potential of earning millions.

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Direct Medical Clinic – A Direct Primary Care Model

December 7th, 2021

How to Promote Health,
Decrease Costs, and Lower Premiums

A company’s healthcare costs increase due to unrestricted access to the typical network of hospitals and hospital-owned physicians who are incentivized to perform more procedures and order more referral to specialists.

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Ysletta Independent School District Seeks Insurance Consultant

December 6th, 2021

Ysleta Independent School District has 38,000 students and approximately 6,000 employees.

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Reference Based Pricing Quandary – Medicare Cuts & New Government Mandates

December 6th, 2021

The new Surprise Billing and Transparency rules to take effect in 2022 will be a game changer for Reference Based Pricing plans. Add to that the upcoming 10% Medicare cut to physicians.

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Rx Assistance For Hot Potato Health Plans

December 5th, 2021

THE HOT POTATO RISK TRANSFER METHOD

Hot Potato Health Plans are a growing market phenomenon. These plans have found a solution to high-cost specialty drugs through a common sense risk transfer method.

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TRS Board Meets On Pearl Harbor Day

December 4th, 2021

“You won’t believe what they are going to talk about………….”

TRS:  Notice of Webcasts – Dec. 7-8 Board Meeting

We’d like to inform you of our next board meeting webcast on Dec. 7-8, 2021. The board meeting will begin at 8 a.m.

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School District Experiences Underwriting Miracle Offer They Can’t Refuse

December 4th, 2021

Here’s proof miracles do happen within the deep recesses of the underwriting world…….

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School District Blasts Gallagher’s Greed In Health Plan Choice

December 3rd, 2021

“Unknown to the School Board, Gallagher had received secret insurance commissions over the years totaling millions of dollars.”

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Reason & Logic Applied To The Great Feardemic

December 3rd, 2021

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Socialism Applied To Underwriting

December 3rd, 2021

Consultant: Rate this without specialty drugs. We plan to exclude all specialty drugs.

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Jury Finds UnitedHealthcare and Affiliates Guilty of Oppression, Fraud and Malice

December 2nd, 2021

“United’s Shared Savings Program takes up to a 50% administrative fee on the difference between billed charges and United’s arbitrary payments. United often receives more money on their shared savings fee than they pay to the provider.” 

So, what else is new? This happens all the time. Most plan sponsors don’t know anything about this. Here is another example, Aetna’s shared savings of +9% (Weslaco ISD vs Aetna) And how about Oakland County vs BCBS? Cigna vs Anheiser Busch? There are hundreds of lawsuits over the years addressing this practice. – Bill Rusteberg

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AMA: Individualism & Meritocracy is Malignant & Genitic Screening Is Racist

December 1st, 2021

Doctors Warn New Medical School Guidance Would Lead to Unqualified Physicians and Unscientific Medicine

Accreditation guidelines call meritocracy ‘malignant,’ suggest genetic screening is racist

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A Cure for Type 1 Diabetes? For One Man, It Seems to Have Worked

November 27th, 2021

Frederick Banting Discovered Insulin in 1923

A new treatment that cures diabetes 1? That’s gonna be one hell of an expensive drug! Unless the spirit of Frederick Banting rises from the laboratory once again.

Frederick Banting was the man who discovered insulin – and gave it away for free (diabetescommunity.com)

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NOW YOU’S CAN’T LEAVE! Starring TRS ActiveCare

November 27th, 2021

This (TASB LEGAL – see link below) seems to be contrary to the general understanding many districts have that a TRS ActiveCare member district which opts to continue participation effective Sept.1 2022 may exit the program any year they choose after that. Instead, according to the document below, it appears they are locked in for five years.

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How Nonprofit Hospitals Get Away With The Biggest Rip Off In America

November 27th, 2021

SOURCE: www.medicaleconomics.com

“Nearly two-thirds of our nation’s 5,000 hospitals, or around 3,900, call themselves nonprofit, a designation that allows them to avoid paying taxes.”

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Three Risk Transfer Strategies No One Talks About

November 19th, 2021

With their financial backs to the wall what are plan sponsors to do these days in maintaining an affordable and usable health plan for their employees?

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How Drug Money From Sick People Really Works

November 19th, 2021

Rebates are commissions.

So Joe Sixpak goes to the pharmacy to fill his diabetes prescription drug. Between Joe and his insurance plan the pharmacy is paid $408. The pharmacy keeps $69. Where does the rest of it go? Read the rest of this entry »

New York Times Columnist Responsible For Spike in Cardiac Related Medical Encounters

November 19th, 2021

WARNING TO HEART PATIENTS!

A New York Times columnist issues proclamations leading to a significant spike in cardiac related medical encounters among it’s broad base of readers. Reader discretion is advised.

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The TRS ActiveCare Dating Game

November 18th, 2021

Who will she pick? Blue Cross #1, Blue Cross #2, or Blue Cross #3?

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RiskManagers.us Fees Increased Due To Rapid Inflation

November 17th, 2021

RiskManagers.us, a fee based insurance consultant, is raising fees upon contract renewal due to robust inflationary pressures. Cost increases include E&O policy premium increases, travel expenses and continued taxation amounting to +40% of revenue. Additional expenses include legal, accounting, and outside specialty consulting retainers paid to special practice experts.

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You Can Lead A Horse To Water…………………

November 16th, 2021

A Texas City Gone Politically Tone-Deaf

By Josh Butler

“Your attempts to raise taxes …..have been rejected, twice.  Turn your attention to your health plan.  It is the single most significant area of opportunity, but you are not taking advantage of it currently.  What will it take?”

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Prediction Comes True

November 15th, 2021

Prediction that COVID Has “Small Impact” in Health Insurance Carriers Becomes Reality

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Why Do We Continue Feeding The Beast?

November 15th, 2021

Source: Linkedin, Author Unknown

Stunning Graph. There’s no question this trend will continue. 20 of 20 years have an increase… We’re up 400% in that time frame.

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Meanwhile South of The Border – The Mexican Healthcare Solution

November 12th, 2021

The American solution to solving the uninsured problem was the Affordable Care Act. The Mexican solution is different.

Seguro Popular is Mexico’s solution to protect their uninsured population. It’s benefit structure is disease based. It’s cost basis is income based. No one is forced to participate and no one is penalized if they don’t.

Maybe we could learn something here as this seems to be a practical, common sense approach to universal healthcare.

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Veterans Day 2021

November 11th, 2021

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. 

The battalion began the battle of Hatten with 33 officers and 748 en- listed men. Fifty-two hours later it had an effective strength of 11 officers and 253 enlisted men. All others were either killed, wounded or missing in action.

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Ha! It’s None of Your Business!

November 10th, 2021

New broker disclosure rules taking effect 27 December 2021 have most health insurance brokers and consultants running scared. But reptiles earning undisclosed compensation off non-ERISA plans are resting easy. They believe the new disclosure rules don’t apply to them. Or do they?

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David vs Goliath

November 5th, 2021

How can a small school district get better benefits and lower costs than TRS ActiveCare with over 450,000 members?

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Texas SOL Law Limits Runout Liability

November 4th, 2021

Texas has a law requiring that health care service providers bill a patient no later than the first day of the 11th month after services were provided.

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Leveraging Behavioral Economics To Solve Health Care

November 4th, 2021

Free cash flow is created by attracting a disproportionate number of high claimants (the Super Utilisers) to enroll (spin-out) in alternate group coverage by offering them 100% medical coverage with zero out-of-pocket expenses. They voluntarily elect coverage*.

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New Broker / Consultant Compensation Disclosure Rule To Take Effect

November 3rd, 2021

The days on “Don’t Ask, Don’t Tell” is coming to an end 59 days from now…….

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How Montana Is Revolutionizing Healthcare—With Markets

October 31st, 2021

If direct pay models became commonplace, they would empower and liberate both patients and doctors and do more to bring down costs than other healthcare reforms.

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Mask Stupidity

October 30th, 2021

Masks don’t work so why wear them? For those of you still wearing your Obedience Mask, how many more years are you going to wear them? Forever?

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Found Money ? The Golden Goose WIMPER Plan

October 29th, 2021

Imagine being able to provide more employee benefits for free at no cost to either the employer or employee. Sounds too good to be true doesn’t it? Well…………..you might be surprised or…..you might not…………….

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Billionaire Investor Enters The Drug Business

October 26th, 2021

“Is This Cuban’s IPO? Buy, Buy, Buy Now!”

Billionaire Mark Cuban’s New Firm Seeks to Reduce Drug Costs

When it comes to lowering America’s notoriously high prescription drug prices, who better to haggle on your behalf than a loud-mouthed NBA team owner best known for bullying referees and hosting a reality TV show?

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PBMs Must “Spill The Beans” Under Texas Statute

October 26th, 2021

Now as a matter of public record you can find out more about your PBM’s revenue streams earned from pharmaceutical drug manufacturers under a Texas statute and TDI amendment to the Texas Insurance Code.

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