ASC Sues Aetna Over “Mystery Repricing Program”

October 16th, 2021

Aetna repriced $233,988 to $33,380. Inquisitive minds want to know why………….

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Surprise Medical Bills & Reference Based Pricing

October 15th, 2021

The old saying “The plan pays what it’s going to pay, nothing more and nothing less” will now have to necessarily say “The plan pays what an outside arbitrator says it will pay, nothing more and nothing less.”

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Claim Audit Exposes Managed Care Reimbursement Levels

October 14th, 2021

2016 audit of BCBSTX claims shows paid amounts for “emergent” services were in excess of ten times Medicare fees…….

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Today’s Primary Care Problems Can Be Solved by Advanced Primary Care

October 13th, 2021

Employers are ditching traditional care methods for Advanced Primary Care………….

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Former Insurance Commissioners Gets 7 Years In Prison

October 13th, 2021

Georgia’s former insurance commissioner was sentenced Tuesday to just over seven years in federal prison and ordered to pay restitution of $2.6 million on 37 counts of mail and wire fraud, money laundering, and aiding the filing of false tax returns.

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Why Pay For Health Insurance For Those That Don’t Need It?

October 12th, 2021

A Hidden Nugget In The Affordable Care Act

By Bill Rusteberg

A Plan Sponsor may be wise to consider a risk transfer strategy through a program created by the Affordable Care Act but which few plan sponsors are aware of.

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Predicate For Vaccine Mandate is False

October 12th, 2021

“If the proposed mandate cannot guarantee that the individual vaccine recipients are protected against breakthrough infection, nor prevent the spread of the infection to at-risk people (vaccinated or not), then the mandate is based on a false premise.”

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Attention: Hospitals & Their Attorneys Are Prohibited From Reading This Blog

October 11th, 2021

In deference to one of our three readers, effective immediately we are prohibiting hospital people and their attorneys from reading this blog.

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Crack Healthcare Costs with Cash

October 11th, 2021

Mike Dendy wrote about the OPEC of Healthcare, a brilliant analogy that illustrates the intended and unintended consequences of 50+ years of unbridled growth in third party administration. It’s also a great reminder of how everything, even OPEC, can change…

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Hospital Rejects 120% of Medicare, Accepts 105% Instead

October 11th, 2021

If a hospital rejects 120% of Medicare reimbursement and turns non-emergent patients away, why do you think the same hospital would accept 105% instead?

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MediShield

October 10th, 2021

An add-on service providing Reference Based Pricing legal support for possible balance bill escalations or litigation…………………

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RxPharmacy Assurance Launches Innovative Stop-Loss Supplement to Manage Pharmacy Risk

October 10th, 2021

A supplemental stop-loss product for unexpected and potentially catastrophic specialty drug claims? How’s that possible………………..?

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How A West Texan Turned A Small Pharmacy Into A National PBM

October 8th, 2021

Jerry Hodge had an opportunity and the vision it took to recognize it’s potential but he didn’t have the credit or the money to seize upon it.

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TPA Administrative Services Agreement

October 8th, 2021

By Bill Rusteberg

Yesterday we reviewed a TPA Administrative Services Agreement. It was same old same old until we got to page 13.

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Bureaucratic Red Tape Delays Compassionate Use Basis

October 8th, 2021

By Marty Makary MD

If we wanted to, we could instantly slash daily Covid death rates in HALF (or more) with one pill.

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The Great Money Grab

October 7th, 2021

Be Afraid, Very Afraid

By Molly Mulebriar

“You don’t want me to know your business because it won’t be good for you” said the physician group’s business manager some years ago.

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RBP Vendor Offers More For Less

October 7th, 2021

By Bill Rusteberg

As RBP grows so will the number of new entrants into the market with improved benefits and competitive pricing. That’s good for business.

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Why Are Carriers Dragging Claims These Days?

October 7th, 2021

Side note to the Kaiser article below brings two observations:

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Hospital System in Colorado to Refuse Organ Transplants to Those Without Covid Jab

October 6th, 2021

A hospital system in Colorado has now announced that they will be refusing organ transplants to all patients who haven’t received a vaccination against Covid-19.

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Texas Businessman Reacts To Government Vaccine Mandate

October 6th, 2021

The restaurant business is a tough business. Add to that onerous government mandates and it’s even tougher. But this restaurant owner has had enough……………….

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Chinese Flu Anti-Vax Punishment Ok’d by Government

October 6th, 2021

Government dictates employers can punish employees who refuse to take a Chinese Flu vaccination…………….

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Cash Beats Managed Care Plans Every Time

October 4th, 2021

Removing Financial Barriers To Health Care

This is how to remove all financial barriers to healthcare, improve benefits, and save money at the same time.

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What the Broker Compensation Disclosure Rule Means for Employers

October 4th, 2021

Undisclosed broker compensation can be enormous. Take the case of a Texas public school district in the Lower Rio Grande Valley who thought their broker was earning $126,000 in fees.

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Have You Read Your RBP Contract?

October 3rd, 2021

Stop! Don’t Sign Until You Read It!

Years ago a client signed a contract before we had the chance to review it. When we did we found the vendor was royally screwing the client with new terms and conditions not memorialized in their winning proposal.

I asked the owner who happened to be an attorney too, “Did you read the contract before you signed it?” He bowed up and said “Yes, of course I read the contract!” 

“Then why did you sign it?” I countered.

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Plan Sponsor Refuses Advice and Pays Dearly For It

October 3rd, 2021

Please, Oh Please, Take This Advice

By Bill Rusteberg

It’s sad how much drugs are costing these days. Most plan sponsors are simply “sucking it up” and paying for these abusively high and egregious prices funded by rate increases passed on, in part, to plan members.

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Texas Broker Captures 150 School Districts

October 2nd, 2021

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson

The Texas Schools Health Benefits Program (TSHBP) is a commercial health insurance program developed for Texas school districts by FBS, a Dallas insurance brokerage.

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Wall Street’s Buying Up U.S. Health Care

October 2nd, 2021

What happens when Wall Street takes over health care? You may not realize it, but private equity firms — which invest money for wealthy individuals, pension funds and endowments — are buying up medical practices and hospitals all over the U.S., expecting a big return on their money.

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Health Care Profits For Me, But Not For Thee

October 1st, 2021

Companies and lobbying groups often paint their business foes as the primary problems with the health care system……………..

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More Americans Can’t Afford Drugs Anymore

September 30th, 2021

“Drug Prices Are Too Damn High”

The most recent West Health and Gallup survey reports that 7% of U.S. adults were unable to pay for at least one prescription medication between March and June of 2021.

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Sad Story With Happy Ending

September 30th, 2021

When Warner saw that his insurance company paid nearly $17,000 toward the $54,000 charge for a covid test, he first thought: “At least I’m not liable for anything”

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Innovative Risk Sharing Strategy You’ve (probably) Never Heard Of…………

September 29th, 2021

“Granular Insurance places self-funded employers on a path of certainty with its multi-year rate and benefit guarantee: a meaningful cap on annual premium increases with moderate and predictable changes to an employers’ spec.”

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RBP PPO Wrap For $1.50 PEPM

September 28th, 2021

Rental PPO Competitor Reacts To The News

We’ve learned there is a national PPO network active in all 50 states that works as a wrap to  RBP plans for an access fee of $1.50 PEPM. This network is Medicare based and has negotiated direct provider agreements at less than 200% of Medicare.

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H.H.C. Group Provides Professional Claims Negotiation

September 28th, 2021

Professional claim negotiators can often resolve balance billing issues in five days or less………..

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How One Texas School District Revolutionized Healthcare for Schools

September 28th, 2021

Tired of waiting for the Texas legislature to act in addressing crippling health care costs affecting hundreds of thousands of Texas educators, in 2019 the Raymondville Independent School District in deep South Texas decided to act.

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Rx Manage

September 28th, 2021

This Rx program can be offered alongside any PBM administered plan. Rx savings are significant.

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Removing Financial Barriers To Health Care

September 27th, 2021

A primary care centric model coupled with directed referrals and cash pay strategies is the best way to lower costs, improve benefits (by removing financial barriers to healthcare) and improve member satisfaction. Why not try it?

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Centivo Raises Additional $51 Million

September 26th, 2021

Centivo’s market momentum is verified by significant savings and improved clinical results………………….

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On-Line Pharmacy Delivers Rx Savings

September 26th, 2021

AFFORDABLE MEDICINE FOR ALL

Your online pharmacy for low-cost, generic medicine, delivered right to your door – all without asking for your insurance information.

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Chinese Flu Crib Sheet

September 23rd, 2021

The survival rate of “Covid” is over 99%. Government medical experts went out of their way to underline, from the beginning of the pandemic, that the vast majority of the population are not in any danger from Covid.

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HMS

September 23rd, 2021

We make healthcare work better for everyone. By reducing costs and improving health outcomes, HMS advances the healthcare system.

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340b Benefits Who?

September 23rd, 2021

The 340b program has become a huge revenue generator for health systems, PBM’s, and other intermediaries.

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Grab Your Share of $345,000,000 Today!

September 22nd, 2021

“We getting a refund Bruno? That’s cool!”

There is a class action lawsuit settlement of $345m reached between the plaintiffs (Pfizer & King Pharma) and any person or entity that purchased brand or authorized generic Epipens between 8/4/2011 and 11/1/2020.

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2022 Onsite Employee Health Clinics Summit

September 22nd, 2021

Onsite employee health clinics have proven to be an effective way to significantly reduce healthcare costs, and ultimately, have a positive impact on the company’s bottom line.

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Direct Primary Care Rocks

September 22nd, 2021

Primary care physicians can treat 90% of what ails you. Direct primary care is a model that makes sense and saves money, provides better personal service grounded upon a holistic health care approach.

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Mike Dendy on Reference Based Pricing

September 22nd, 2021

By Mike Dendy

Reference based reimbursement (RBR or RBP) has evolved over the past 10 years and there are now many more players in the space.

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Doctor Arrested For Prescribing Ivermectin

September 21st, 2021

Dr. Jean-Paul Theron was arrested for prescribing Ivermectin from his home. He was targeted by a complaint from the Council of the Order of Physicians……..                                           Read the rest of this entry »

Dentists Chip Away at Uninsured Problem by Offering Patients Membership Plans

September 17th, 2021

“Patients on membership plans act like insured patients and come in as much as insured patients, but they pay less for coverage while dentists get paid more,” said CEO Dave Monahan. “All we are doing is cutting out the middleman,” he said.

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Sex Sells – Winning Sales Quota by Banging Doctors?

September 17th, 2021

In 2012, Insys hired a new sales executive: Sunrise Lee, a Florida escort service manager and former strip club dancer with no academic degree, according to Guzman’s complaint. Burlakoff allegedly defended the decision, claiming, “Doctors really enjoyed spending time with her and found Sunrise to be a great listener.” He added, “She’s more of a closer.”

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Dallas Risk Management

September 17th, 2021

Dallas Risk Management (DRM) is a Managing General Underwriter, or MGU, for health insurance policies.

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Key House Democrats Block Biden Drug Price Controls

September 17th, 2021

Key House Democrats Block Biden Drug Price Controls – Lunch Alert! – DickMorris.com at DickMorris.com

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Embodiment of Corruption: Your Health Insurance Network

September 16th, 2021

Secret network pricing helps render patients defenseless against price gouging. It’s as absurd as grocers being permitted to keep the price of milk secret……………..

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Texas Hospital Faces Closure Over COVID-19 Vaccine Mandate: CEO

September 15th, 2021

“What happens to individual choice and medical decisions between the patient and their doctor, which is all of the things that we’re trying to support.”

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TRS ActiveCare Will Remain The Choice of +90% of Texas School Districts

September 15th, 2021

For the first time in 20 years TRS ActiveCare member districts will be allowed to opt out of the program effective September 1, 2022. In our opinion most member districts will remain in TRS ActiveCare.

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Why Most Public School Districts Get An “F” In Health Care Management

September 13th, 2021

By Bill Rusteberg

School districts are entitlement based bastions whose decision making processes heavily weight social considerations at the expense of prudent business practices.

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Fellow Health Care Disruptor Shares Personal Experience

September 12th, 2021

A friend,  fellow health care disruptor and collaborator shared his personal experience navigating the American Health Care System in an email sent us this afternoon.

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U.S. v. Teva Pharmaceuticals USA Inc et al

September 12th, 2021

Lawsuit alleges the company illegally paid two purportedly independent charitable foundations $328 million from 2006 to 2015 to cover co-payments of Copaxone patients, while Copaxone’s price quadrupled to $73,326 a year.

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Paul Keckley – Trusted Advisor

September 12th, 2021

Paul Keckley is an intense observer of that change, diving deep into the trends, tipping points, intended and unintended consequences to bring clients and opinion leaders the unvarnished truth.

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Customers Get Fired Too…………

September 11th, 2021

By Dan Meylan

“In 5 decades of operating agencies and other businesses….we always looked for ways to remove unprofitable clients….”

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Pissed Off Plan Sponsor Has Had Enough!

September 11th, 2021

Pissed off plan sponsor has had enough! Their TPA has not lived up to expectations and a warning shot has been fired across the TPA’s bow……………

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American Health Care System Drives Man To Drink

September 10th, 2021

Called for an appointment……………………

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Employee Benefits International

September 9th, 2021

Employee Benefits International is headquartered in Phoenix, Arizona, and covers the entire United States with health insurance and employee benefits programs for businesses – large and small. EBI has experts in-house that have worked with most business sectors including: healthcare, law firms, construction, manufacturers, nonprofits, auto dealerships, Realtors, and many others.

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Legendary Insurance Agents You Never Heard Of

September 9th, 2021

“Rosengard is known for putting together what was for a long time the world’s largest life insurance policy, still recorded by Guinness Book of Records.”

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CPO Centric Health Plan

September 9th, 2021

By Bill Rusteberg

A CPO (Cash Pay Option) centric health plan removes all financial barriers to health care while saving money at the same time. Cash beats insurance everytime.

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Selecting a Third Party Administrator

September 8th, 2021

By William Rusteberg

With the growing suggestion that the BUCAs are inflexible third party administrators unwilling and unable to administer Reference Based Pricing plans and other strategies in the market today, more brokers are seeking new partnerships with independent third party administrators (TPA). An independent TPA can offer much more than a traditional carrier model.

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La Joya ISD Shit Show Continues………………..

September 6th, 2021

FBI agent and a law enforcement officer from the Texas Department of Insurance watched quietly from the gallery as the the never ending La Joya Shit Show Continues…………….

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Politicians Begin Watering Down Efforts To Lower Drug Pricing

September 6th, 2021

Senate drug pricing bill may not apply to those with job-based insurance

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Rx Rebates 101

September 6th, 2021

The role of rebates in drug coverage decisions and insurer finances…………

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What Ever Happened To………………………?

September 3rd, 2021

Apr 12, 2018 · An insurance broker who admitted paying bribes to land lucrative health insurance contracts at area school districts and the now-defunct water utility was sentenced to 37 months in prison.

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Medicare Is Running Out of Money

September 2nd, 2021

Medicare is running out of money. That’s not news to plan sponsors. They too are running out of money to fund the American health care beast. Some propose “Medicare for All” as the solution. Others say “Let the free market handle the problem!” The problem is there is no free market in health care and Medicare is running out of money because government doesn’t know how to solve health care either. Meanwhile, a few plan sponsors have solved health care the old fashion way using traditional American business practices based on common sense, reason and logic.

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Medical Debt Collector or Patient Assistance? Nonprofit’s Model Raises Ethical and Legal Questions

August 31st, 2021

Hospitals are donating unpaid debt to a Tulsa-based not-for-profit that claims to connect patients with social services including housing help, food assistance, transportation, addiction treatment or credit counseling.

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Participate In Stop Loss Profits

August 31st, 2021

Trucking coverage is tough right now. Thanks to nuclear verdicts and low interest rates, premiums are climbing. This is happening to all companies, regardless of their loss experienc

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You Can’t Fix What You Don’t See

August 30th, 2021

candle

By William Rusteberg

Has your company tried, over and over again, to solve ever increasing health care costs?  “Yes, of course we have, but nothing seems to work!” is a common answer. “We bid out our employee health insurance every year through multiple brokers, we reduce benefits to offset rate increases, and we even light a candle 24 hours before year-end renewal!”

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The Klement Letter

August 29th, 2021

“As an outsider looking in and not having all the political implications and considerations that board members face, I’d like to give you our perspective and advice for consideration on your choices.” – Greg Klement

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Mike Keogh

August 29th, 2021

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson

By Bill Rusteberg

Mike Keogh was an extraordinary man. A former BCBSTX salesman in the 1950’s, he later built  an independent brokerage in San Antonio with great success. I met Mike in the early 80’s and did quite a bit of business with him.

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United States Health Care Pricing Is Insane

August 28th, 2021

Does anyone with health insurance really care what health care costs? After all, with copays and deductible/s the same cost to the consumer no matter where they go for care because other people’s money pay most of the cost……………..

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