“The medical loss ratio is going to cause most if not all truly professional agents to vacate the health insurance market,” stated a NAIFA Member from Oxford, Miss.

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       Has Randall Childers lost his marbles? Or is he one step ahead of the market? We thought this was our idea (yes we invented the weed eater too, just didn’t get the necessary patent).

http://web.me.com/randall_childers/FRC_Consulting/Medical_Plan_Matrix.html

Editor’s Note: Unbundling components of a self-funded health plan makes sense, and saves money. Unfortunately many TPA’s have “veto” power over selection of subcontractors.  This kind of TPA control may affect the financial health of the Plan Sponsor as well as fiduciary duties.

From A South Texas Insurance Consultant:         Damn, why did we not think of this approach????

From A Midwestern Insurance Consultant:         Whoa! What a friggin genius!

While cost increases for families enrolled in employer-sponsored preferred provider organizations have slowed since 2010, average total costs per family still hit an all-time high, according to a report released Tuesday by Seattle-based Milliman Inc.

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http://self-insuranceworld.blogspot.com/

“I received your balance due notice indicating I owe $[Amount Due] on the account. Please be advised that I do not believe the charges to be a reasonable price for the services rendered.”

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If you are a political subdivision and need the expertise of a qualified insurance consultant but you just don’t have the time or patience to seek a  competitive RFQ, then Edinburg Independent School District may well have done the work for you.

The Edinburg Independent School District is currently in the process of selecting an insurance consultant to assist the district in their insurance needs. Ten (10) insurance consulting firms are competing for the business.

The vetting process appears to be over and the district has now ranked the contenders as follows: https://v3.boardbook.org/Public/PublicItemDownload.aspx?ik=32420281

The Brownsville Independent School District is also considering hiring an insurance consultant ( http://blog.riskmanagers.us/?p=7913 ) will the same consultants vie for the business? If so, will they be ranked the same?

Since the services of an insurance consultant are professional services exempt from state bidding requirements, some consultants do not participate in public bids as a matter of design. Submissions become part of the public record and can provide usefull data to competitors. And, if your ranked poorly you forever bear a Scarlet Letter.

Editor’s Note: Many of these contenders compete for business against each other throughout Texas. While one school district may rank a contender #1, another district will rank the same contender #2, or 3, or 4, etc. Does this prove that consultants are ever changing from good to bad, from bad to good, or good to better depending on the position of the Sun, Moon and stars?

Attendees will learn industry secrets that others in the managed care industry are afraid to tell you. You will learn how other Texas employers have reduced their health care costs by 40% or more while improving benefits at the same time. You will learn unique riskmanagement techniques that are proven and quantifiable. You will become empowered.

www.costplusinsurance.com

If a medical provider, such as a hospital, won’t publish their charges or even tell a prospective patient what an upcoming visit will cost them, why then should a patient tell them what they are willing to pay for the services rendered?

In essence, the hospital is saying to the patient, I won’t let you see my prices but I want to see your checkbook (proof of insurance) before we do business.

So you show your checkbook (proof of insurance) to the admissions clerk. You also sign a document allowing your bank (insurance company) to send payment direct to the hospital once a claim (demand)  is filed. A section of the document states that whatever your bank (insurance company) does not pay, you are responsible for any unpaid balance.

Unknowing to the clueless insurance clerk, you have not told them how much is in your checking account - you only showed them that you have one. That’s fair, because after all the insurance clerk did not disclose what the visit would cost, so why should you disclose  how much is in your checking account! Fair is fair as they say in Buffalo Breath, Montana.

By entering into an Assignment of Benefits, the hospital has legally “stepped into the shoes” of the Plan Document (PD). The PD governs how claims are to be paid, upon what basis and parameters stiplated therein. It also outlines, as required under ERISA, an appeals process for providers to follow should all or part of their demand is denied.

The hospital files a demand for $250,000 to your checking account. The bank president writes a check off your account for $50,000 and sends it to the hospital. That was all the money availble to be paid on this claim, no more and no less.

Unfortunately, the hospital is not happy and demands that the you pay the balance, or $200,000. But, since they accepted assignment of the claim, the Plan Document became the undesputed rule book. What now?

One of the rules requires the hospital to file an appeal, or a series of appeals to recoup moneys denied by the payer (the payer is now the insurance policy, not the patient).

The patient, through the Assignment of Benefits, has effectively established a contract with the provider.

Fortunately for the hospial, under ERISA,  providers have 60 days to appeal. Failure to appeal a denial within the 60 day period can result in the forfeiture of a provider’s right to reimbursement or even access to court. A provider may have to complete two or more levels of appeals before they can file a lawsuit in federal court to pursue their legal right to reimbursement.

With Cost Plus and Medicare based reimbursment plans growing in the market, the phenomenon of balance billing is playing hard on the minds of human resource directors. HR directors fear balance billing as much as Superman’s adversion to Krytonite. But an assignment of benefits, in the view of some legal experts, is consideration in full, leaving balance billing issues mute.

Statistics show that under Cost Plus Plans and Medicare Based Reimbursment Plans,  only 7% of providers ever file an appeal. That means 93% have effectively given up their legal remedies under ERISA to recoup denied revenue.

If Assignment of Benefits were not in play, then the insured would be the recipient of eligible claim dollars. Imagine Joe Sixpack receiving the $50,000 check. He could then negotiate with the hospital – “I’ll give you $40,000 for payment in full or nothing at all buddy. Your charges are outrageous!”

Isn’t this how automobile insurance works? You get a check from the insurance company, then go out to shop for the most competitive repair shop in town? You may even pocket some easy cash along the way.

From a Texas provider:

- Great points, Bill. If prices aren’t openly discussed, they will only increase

“At some point in time health care is going to so dominate commerce and so dominate costs in the United States, so dominate our economy it’s going to cause our economy to collapse. What we’ve gone through in the last couple of years is going to be nothing compared to what we will go through when health care is 25 to 30 percent of every dollar spent in the United States. And that’s only going to be in the next 10 to 15 years.”

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Under an Assignment of Benefits, the patient and provider have dictated the terms of their own contract.

A-Little-Consideration-If-You-Please!