
“A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose………….”
Read the rest of this entry »“A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose………….”
Read the rest of this entry »When comparing insurance costs, using premiums does not present a realistic comparison; use rates. Divide the premium by the exposure (values, number of vehicles, cost new of insured vehicles, number of students).
Read the rest of this entry »By Bill Rusteberg
Lasers have been unfairly treated and it’s time to show a little respect!
Read the rest of this entry »The Transparency in Coverage Final Rule and Texas House Bill 2090 require disclosure of the negotiated rates with in-network providers and the historic allowed amounts paid to out-of-network providers, for all health plans available to employers. Files containing this information for the plans covered are published on this page.
Read the rest of this entry »Murray was a most amazing character and ended up selling me life insurance….. at 27 years old!
Read the rest of this entry »Brownsville ISD board members debate the value of their health insurance broker at a Brownsville ISD Insurance Committee Workshop on May 13, 2020.
There is a difference between managing risk and servicing risk. Legacy health insurance brokers provide the later. New era health insurance brokers provide the former leaving TPA’s to service the risk.
Read the rest of this entry »By Josh Butler
I’ve got a brilliant idea….What is it? Let’s make buying prescriptions sooo complicated, no one will ever be able to understand it….
Read the rest of this entry »“Like a good neighbor, State Farm is there – and here and in my bed with my wife!”
Read the rest of this entry »Tesla dispute – top auto insurers writing off rather than repairing crashed Tesla EVs
by Mary Or 31 Jan 2023
Auto insurers have been writing off crashed Tesla EVs and sending them to salvage auctions instead, deeming many too expensive to repair.
Read the rest of this entry »(1) Crank up the printing presses and gift more money to health insurance companies to pay for out of control health care costs and (2) Gift stolen wages from working class Hyphenated-Americans to health insurance companies to pay for out of control health care costs.
“Bill provisions include making enhanced subsidies (OTHER PEOPLE’S MONEY) for Affordable Care Act Health Insurance Marketplace coverage, extended through 2025 in the Inflation Reduction Act, permanent; designating the second-lowest-cost Gold plan the benchmark plan upon which premium subsidies (OTHER PEOPLE’S MONEY) are based; and increasing the value of cost-sharing reduction (CSR) assistance for those with income between 100 and 250 percent of FPL (Federal Poverty Level) while expanding eligibility for CSR assistance to people with income up to 400 percent of FPL.”
Read the rest of this entry »Hiding Behind A Logo is a traditional American health care finance method of controlling the irrational correlation between cost of services and goods to end-user pricing while protecting ever increasing revenue streams from public display at the same time.
Read the rest of this entry »Barb Teron, a book buyer in Brook Park, Ohio, plans to delay her retirement because she is worried about Humira’s cost. Ms. Teron, who takes Humira for Crohn’s disease and colitis, has never had to pay more than $5 for a refill of the drug because her employer’s insurance plan picks up most of the tab. The cost, according to a pharmacy app on Ms. Teron’s phone, was $88,766 in the past year.
Read the rest of this entry »By Justin Nutt
A study in the U.S.A found that the most productive age in human life is between 60-70 years of age.
Read the rest of this entry »Hospitals are now required by federal law to publish the prices of mammograms, CT scans and hundreds of other procedures.
Read the rest of this entry »Medicare pays through the nose for services rendered by frugal doctor……….
Read the rest of this entry »“Daddy, who do you think you are, a doctor or an insurance company? Since insurance companies have always paid you and not your patients, doesn’t that mean you’re an agent of the insurance company?”
“Not any more son. Screw insurance companies! I work for my patients now” Dr. Doogood chortles.
Read the rest of this entry »Cash Pay Centric Health Plans are becoming a growing market trend, catching the attention of plan sponsors and government officials. The strategy is based on common sense, reason and logic applied to health care, something long missing from American health care financing.
Read the rest of this entry »Jack Sullivan who murdered John Bradbury, a railroad officer, during a gun fight, is seen smoking a cigar a few moments before he took his last breath in the lethal gas execution chamber at the state prison on May 17, 1936 in Florence, Arizona. / AFP PHOTO / ACME / – (Photo credit should read -/AFP via Getty Images)
Read the rest of this entry »“It seemed like the theme park ride vehicles were getting smaller, and I was getting bigger…..”
Read the rest of this entry »By Bill Rusteberg
Years ago a hedge fund operator called seeking information on Reference Based Pricing, a nascent but growing market trend at the time. He continued calling over the next six months to which I was happy to share my experience, both good and bad, with Reference Based Pricing.
Read the rest of this entry »Doug Aldeen takes a deep dive into Reference Based Pricing
JANUARY 23, 2023
Julianne calls up Doug Aldeen, ESQ an ERISA Healthcare Attorney and General Counsel to discuss the Reference Based Pricing (RBP) landscape, specifically how RBP has evolved over time.
Read the rest of this entry »J Patrick Rooney is considered by many to be the Father of Margin Based Pricing better known these days as Reference Based Pricing. Many believe his conclusion of what the “sweet spot” reference point should be still holds true today.
Read the rest of this entry »Turbocharge your chargemaster then offer payers 50% off double the price………..
Read the rest of this entry »Introducing RxPass from Amazon Pharmacy, a $5 prescription subscription that helps Prime members who take multiple medications save time and money
Read the rest of this entry »New Drugs for Weight Loss: What Plan Sponsors Need to Know
The latest generation of prescription drugs originally developed to help people manage their type 2 diabetes have been causing quite a stir for patients, health professionals and benefit plans, now that they’ve been approved and are being promoted to treat weight loss. Health benefit plan sponsors who are presently excluding weight-loss drugs from coverage are revisiting coverage rules because of the effectiveness and demand for these newer weight-loss drugs.
Read the rest of this entry »Employees Using Centivo Also Visited Primary Care Physicians More and Experienced Fewer Emergency and Inpatient Visits Than Industry Benchmarks
BUFFALO, N.Y. — Centivo, a new type of health plan for self-funded employers anchored around leading providers of value-based care, today announced key findings from its 2022 healthcare spend analysis derived from the Company’s flagship Partnership Plan offering. The findings reveal dramatic healthcare cost savings for Centivo’s employer clients (21 to 33 percent) compared to widely recognized industry benchmarks.
Read the rest of this entry »School is in session this Friday: Forward-looking #school leaders will join me in sharing the “secrets” to achieving world class healthcare while balancing their budget. Is your school district getting a passing grade on its #healthplan?
Read the rest of this entry »This webinar will feature forward-looking school and union leaders who have followed the Health Rosetta blueprint to achieve the Quadruple Aim (better health outcomes, lower costs and better patient & clinician experience) and no longer needlessly squander money on healthcare. And how you can replicate these solutions.
Read the rest of this entry »The last consultant quit, hence the RFP. That’s unfortunate because the previous consultant is widely considered among the best of the best in our industry.
Read the rest of this entry »Underwriting High Risk Plan Members
“Your employer can ask you for a doctor’s note or other health information if they need the information for sick leave, workers’ compensation, wellness programs, or health insurance” – Uncle Sam
Read the rest of this entry »Since its establishment over four years ago, Libra has changed the face of the insurance industry in Israel and has led moves such as a revolution in car insurance with a shift to a kilometer-based pricing model, pet insurance with online claims payment, and more.
Read the rest of this entry »“All-or-nothing clause”……….”Anti-steering clause”……….”Anti-tiering clause”……….”Gag clause”……….”Most favored nation clause”……….
Read the rest of this entry »With little formal training, a majority of health insurance brokers back in the day were simply spreadsheet artists………………………….
Read the rest of this entry »
Blue Cross settles lawsuit for about $2.67 billion……………………..
The Litigation
The process of the litigation was expensive as well as hard-fought. This is because it involved the creation of over 120 depositions, above 15 million pages, and more than a dozen pleas to dismiss claims of the plaintiffs. This is one of the unique kinds of an antitrust lawsuit and is said ‘historic’ in the court filing.
Read the rest of this entry »Educators Legal Liability Coverage (including employment practices)
Apex is a wholesale broker/program manager specializing in property & casualty insurance for public sector risks. We provide easy market access for local, independent agents to secure superior coverage at a competitive price.
Read the rest of this entry »“Although we will not disclose your identity without your express permission, it is possible that your identity may be discovered during an investigation of the matter reported because of information you have provided“.
Read the rest of this entry »Residents say Geraldine, Alabama is as close to the fictional idyllic 1960s TV town of Mayberry as you can get in real life. Located about an hour outside of Huntsville, the town of less than a thousand is the kind of place where everyone knows their neighbour and most people watch the Friday night football game.
Read the rest of this entry »“The nonrefundable administrative fee increased from $50 to $350. CMS says the case load of disputes is nearly ten times greater than initially estimated, resulting in the fee increase.
Read the rest of this entry »By Jody Bright
In answer to a question posed by a fellow on his Facebook page, what we each do I replied the following:
Read the rest of this entry »Where else in America can you make $1 million a year and play golf three times a week between vacations to Tahiti?
Read the rest of this entry »In 90 days, you could be seeing members of your new practice…………….
Read the rest of this entry »Members decide between Free Care vs Not-So-Free Care at the Point of Service…………………….
Read the rest of this entry »Segal’s analysis shows that in 2022 the most common stop-loss insurance deductible is $250,000, up from $200,000 in 2021………….For a stop-loss coverage plan with a deductible of $200,000, the median monthly per-participant premium was $85.80 in 2022, Segal reported. For stop-loss coverage with a deductible of $500,000, the median per-participant premium was $29.90.
Read the rest of this entry »Must self-insured plans provide essential health benefits?
Question: We understand that the Affordable Care Act (ACA) requires some health care plans to cover certain “essential health benefits.” Does that include our self-insured plan?
Read the rest of this entry »Crowded Waiting Rooms & The Rise of Direct Primary Care
“The percentage of U.S. physicians employed by hospitals, health systems or corporate entities grew from 62.2 percent in January 2019 to 73.9 percent as of January 2022.”
Read the rest of this entry »Skyward Specialty is a rapidly growing specialty insurance company, delivering commercial property and casualty products and solutions on a non-admitted and admitted basis.
Read the rest of this entry »All that we do on behalf of our clients is based upon these realizations:
1. If a loss is large enough, an insurance company will do everything possible to delay or avoid payment.
2. Claim adjusters and premium auditors work for the insurance companies – not for you. They aren’t your buddies. All ties, near ties or even questions go to the benefit of the insurance company.
3. a) Insurance companies and agents make money on what they sell; the more they sell, the more they make.
b) If they don’t have available the particular coverage you need, you may never know you need that insurance until you have a loss.
January 11, 2023 / SkyQuest Technology Consulting Pvt. Ltd. / GLOBE NEWSWIRE / Yahoo / / Read Article
The pet insurance market was worth USD 7.1 billion by 2021 and is projected to reach USD 34.3 billion by 2028, with a high CAGR of 17.2% during the forecast period (2022-2028).
A concierge medicine practice, with revenues primarily based on annual membership subscriptions, thrives without the need to depend on reimbursements or expanded patient panels. Throughout its 20-year history the model has proven to be robust and resilient in the face of economic downturns, high inflation, sweeping healthcare reform initiatives, and most recently, the pandemic.
Read the rest of this entry »San Antonio’s Medical Industry Announces $37 Billion in Sales
More than 1 out of every 6 San Antonio-area workers are employed in health care, and about 50,000 net new jobs have been added in the last 10 years. Butler said the health care sector is easily the largest employer in San Antonio with 172,094 workers in 2015, a 13 percent increase from 2013.
Read the rest of this entry »Affordable Care Act Marketplace enrollment jumps 18% over last year
The Department of Health and Human Services recently announced that there has been an 18% increase in Affordable Care Act health insurance enrollment over last year’s numbers, in a major victory for the Biden administration’s efforts to expand access to health insurance.
Read the rest of this entry »Yet Another Stash Of Classified Documents Discovered During Biden’s Colonoscopy
WASHINGTON, D.C. — The White House is on edge this morning after investigators revealed a fourth stash of classified documents from Biden’s tenure as Vice President was found deep ………..At publishing time, doctors had confirmed the colonoscopy also turned up another hard drive linked to Hunter Biden.
Read the rest of this entry »US Motorcycle Rallies Increase Organ Donations
MyHealthGuide Source: David C. Cron, MD, MS; Christopher M. Worsham, MD; Joel T. Adler, MD, MPH; et al, 11/28/2022, JAMA Network
In this cross-sectional study of 10,798 organ donors and 35 329 recipients of these organs from a national transplant registry from 2005 to 2021, there were 21% more organ donors and 26% more transplant recipients per day during motorcycle rallies in regions near those rallies compared with the 4 weeks before and after the rallies.
Read the rest of this entry »PAR Services Group Seeks to be a Family Home for a High-Quality TPA
MyHealthGuide Source: PAR Services Group, 1/13/2023
Nashville, TN – Cameron Dabir has formed PAR Services Group to acquire, grow, and permanently own a high-quality third party administration business.
Read the rest of this entry »“In economics, a moral hazard is a situation where an economic actor has an incentive to increase its exposure to risk because it does not bear the full costs of that risk. Anytime a party in an agreement does not have to suffer the potential consequences of a risk, the likelihood of a moral hazard increases.”
Read the rest of this entry »Vendor complains of a “simplistic” bidding process that failed to delve deep enough, said its proposal got 303 out of a possible 310 points, but that the state asked “superficial yes-or-no answers” on those 310 questions, treated each question as equally important and refused to accept any explanations from bidders.
Read the rest of this entry »“It’s not fair!” says Johnny “The Group Guy” Jones. “Government subsidizes individual policies but not group policies? That’s gonna put me outa business!”
Read the rest of this entry »Nonprofit hospitals are required to provide financial assistance to low-income patients. Providence health system, however, did the opposite in many cases. Rather than ensuring that low-income patients received the financial assistance they were due, Providence hounded them to pay and sent debt collectors after them when they didn’t, according to a New York Times investigation. These actions were part of an official campaign to boost revenue called “Rev-Up” developed with help from corporate consultant McKinsey. The “Rev-Up” campaign directed employees to tell patients about financial assistance only as a last resort. The result: more than 55,000 patients were pursued by debt collectors when they should have been given a discount.
Read the rest of this entry »Value proposition: “Worry-free, time-saving and money-saving”, with the vision “to provide every enterprise with a harmonious workplace, every family with a dedicated doctor, and every user with a safe and healthy life”.
Read the rest of this entry »Rewarding incompetence puts New Jersey in the lead for the 2023 World’s Dumbest Plan Sponsor Award. Their crowning achievement to date, reaching the world’s highest pinnacle of incompetence, is the case where a hospital billed $674,856 for a patient’s hospital stay, but the state’s health plan paid over $2 million to the provider instead.
Read the rest of this entry »Relating to the establishment of a bundled-pricing program to reduce certain health care costs in the state employees group benefits program.
Read the rest of this entry »88(R) SB 358 – Introduced Version – Bill Text
Sec. 1276.054. SHARED SAVINGS PAYMENT. (a) Except as | |
provided by Subsection (b), if an enrollee who requests a | |
disclosure under Section 1276.052 elects and receives a health care | |
service or supply the actual cost of which is less than the amount | |
disclosed under Section 1276.052, the health benefit plan issuer or | |
administrator shall pay to the enrollee 50 percent of the | |
difference between the amount disclosed under Section 1276.052 and | |
the actual cost, minus any applicable deductible, copayment, or | |
coinsurance. |
Sec. 1511.0052. PURPOSE OF POOL. The purpose of the pool is | |
to provide a reinsurance mechanism to: | |
(1) meaningfully reduce health benefit plan premiums | |
in the individual market by mitigating the impact of high-risk | |
individuals on rates; | |
(2) maximize available federal money to assist | |
residents of this state to obtain guaranteed issue health benefit | |
coverage without increasing the federal deficit; and | |
(3) increase enrollment in guaranteed issue, | |
individual market health benefit plans that provide benefits and | |
coverage and cost-sharing protections against out-of-pocket costs | |
comparable to and as comprehensive as health benefit plans that | |
would be available without the pool. |
BCBS of Massachusetts announces first-in-state value-based contracts with incentives tied to equity
The plan says the move is the first in the state and among the first in the nation to create a financial payment model rewarding providers for eliminating racial and ethnic inequities in care.
Read the rest of this entry »Graph posted by Josh Butler on Linkedin
This graph tells you all you need to know about health care financing. There’s good money to be made working the spread (difference between the yellow line and blue line).
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