In total, prosecutor Mark Roomberg said, the commissions resulting from the rigged contracts were “$2.5 million for the entire group.”
A Medical Bill Review audit of a large, 4,500 life employer group performed in 2016 exposes the truth about PPO “discounts.”
By Mark Flores
Just eight days after a federal court slammed CIGNA with a $13M judgement, 113 of CIGNA’s self-insured clients, along with their Plan Administrators have been named as defendants in a massive fraud lawsuit, alleging the plans “participated in a conspiracy and pattern of unlawful, reckless, and deceptive conduct to conceal an embezzlement and/or skimming scheme”.
The following article illustrates the angst hospitals are undergoing in defending their indefensible and egregious pricing strategies through their PPO collaborators. The solution posed in this article by a hospital advocate is: Identify Reference Based Pricing (RBP) patients and don’t treat them! But that short sighted response brings on Cash Pricing strategies through companies like Asserta Health (www.assertahealth.com) which often times saves plan sponsors even more money than otherwise would have been paid hospitals under a typical RBP plan. Making lemonade out of lemons……………
Most TPAs do not pass on the strong discounts for prescription drugs or do not have access to it. A quality TPA should be offering all prescription drugs at AAC + admin fee.
“You can claim — and many do — that better access provides worthwhile value, but that’s akin to putting lipstick on a pig.” – Brian Klepper
If Medicaid allowed overseas treatment for Hep. C (Harvoni) the savings by utilizing a five star hospital system 495 miles south of Florida would save taxpayers 753 X ($95,000 – $19,000) = +$57 million...
For Information on Health City, contact Sarah Rusk, Health City Cayman Islands
t 345-640-4257 m 345-525-2131 w healthcity.ky
Primary care physicians presented the best return on investment for hospitals
FOR IMMEDIATE RELEASE – September 2016
Apex Management Group (Oak Brook, Illinois) has announced a 4 Year Rate Lock on their APEX Suite of MEC Offerings.
It is the Obama administration, and not the insurers, who perpetrated this heist….
“After I got off the phone with him, I realized: That’s actually just insurance for my insurance,” she said, laughing.
See our detailed directory listing of TPAs, which includes their 2015 revenue, claims business by type and by volume, types of client managed and other contact information.
“We guarantee no “balance bills” to our covered members for the amount taken as a discount from your provider’s retail bill.”
“16% more likely to die if they are admitted on a Sunday compared with a Wednesday” SOLUTION: Eliminate all health care services on Sunday…………..
Imagine being in control of your individual employee healthcare costs. Our low cost network puts you in control of your daily healthcare spend. You decide whether the employee is better off using existing insurance options or pre-paying for the specific procedure. Our pre-paid pricing is based on discounts of up to 70% and can save companies millions of dollars a year.
Texas Super TPA with growing market share is a TPA worth watching…….
Just like sticker prices on new cars, no one ever pays hospital chargemaster rates. So why have them? A previous blog posting (Hospitals Dismiss Significance Of Chargemaster Prices?) offers a possible reason, while the following article does too.
A pack of just two EpiPens costs more than $600 in the United States. To fully comprehend the outrage of this price, you must realize that the epinephrine included in the EpiPen costs less than $10 retail. And in Mexico it’s 25 cents (EpiPen alternative costs pennies in Mexico)
Employers, adept at tracking business expenses, are surprisingly lax when it comes to double-checking healthcare costs.
“We learn from history that we do not learn from history” – George Hegel
“Understanding the cost of health care is directly related to what we agree to pay, more and more employers are questioning managed care contracts upon which their health care costs are based. Many are discovering the truth for the first time.”
McALLEN — A life-saving medication that costs more than $600 in the United States is only a few cents in Mexico.
California medical consumers will enjoy strong new protection against surprise out-of-network medical bills..………..
Health insurers are limiting the physician and hospital options they offer through their plans. TRANSLATION: Insurers are limiting provider choice by eliminating providers who want more money than those willing to work for less.
“The bill would relieve patients from having to pay surprise medical bills out of pocket by requiring insurers to reimburse out-of-network doctors and other health providers a “fair amount” and doctors to accept the payments, said its author, Assemblyman Rob Bonta (D-Oakland).”
“That rate would be 125 percent of the amount Medicare pays for the same service or the insurer’s average contracted rate for the service, whichever is greater.”
Editor’s Note: If California passes this bill into law (very likely), Reference Based Pricing in California will take off in the private sector. No network plans, similar to what we have implemented in Texas since 2007, will have solved the problem of balance billing risk. And if Texas passes a similar law TPA’s like Caprock Health Plans and Continental Benefits, both of which administer Reference Based Pricing plans will achieve new business sales that will make Ben Feldman look like an amateur.
The following article is based on the premise that health insurance is health insurance. In truth, “health insurance” is not insurance at all but has simply become a government mandated welfare assistance program administered by insurance companies and TPA’s.
With ObamaCare in full swing, with little likely hood of meaningful repeal, insurers are targeting population management and statistical metrics to bolster a competitive edge and revenue…..
Hospitals have charge master pricing. Pharmaceutical manufacturers have AWP pricing. Consumers pay neither. These are simply made up numbers from which sellers “discount” their wares/services.
That first number thrown out there serves as an anchor — a first reference point. Every other price becomes an adjustment of that price. Take a hospital’s charge master rates for example………..
Some consumers who pay far more than the cash price of a medication when using health insurance.
“There’s more price transparency and quality transparency regarding a refrigerator than there is about your heart surgery.”
Please Mr. Plan Sponsor, pay me direct. I really am worth it! I used to get $35,000 per year on your 75 employee life group plus an undisclosed bonus. I’m sorry I only showed up on renewal, and I promise I will change that. Please, Please, Pretty Please…………………
As long as health plans, with deep pockets, continue to roll over and play dead, health care costs will escalate to a point the entire health care finance system will implode.
Edinburg, TX–– Leaders at Doctors Hospital at Renaissance Health System (DHR) and Mission Regional Medical Center (MRMC) have signed a non-binding letter of intent (LOI) to explore collaborative opportunities between the organizations.
Today, most drug companies offer large rebates to pharmacy benefit managers on behalf of different health plans and employers to reduce patients’ out-of-pocket costs. The problem is a significant portion of the savings is not being passed onto the public.
The audience was aghast to learn that a specialty drug for Hep.C. earned PBM’s a 45% commission for one course of treatment………..
Pascal Metrics is the field leader in measuring and improving patient safety through advanced Patient Safety Analytics (PSA).
San Antonio, TX – Locally owned BMA (Third Party Administrator of Health Insurance plans) announced today that it has launched a new Web site along with enhancements to its End User Portal. Company officials are excited to make this upgrade to their Web site and enhance the user experience in their end-user Portal.
Cutting out the middle man………………………..
Industry denials notwithstanding, reducing healthcare costs is fundamentally against nearly every healthcare organization’s perceived economic interests.
Specialty drugs are bankrupting self-funded health plans.
An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects.
“No problem Joe, I’ll make a call for you”
Some exchange plans are paying doctors less than Medicaid pays. Blue Cross in Dallas, for example, pays some doctors 10% less than Medicaid’s fee. If insurance buyers were forewarned, that would be one thing. But no exchange plan is advertising that access will be worse than it is for Medicaid patients.
King George III ruled England, Canada and what is now the USA. All three share the same language and are similar in many ways. But health care statistics show the USA a leader in health care delivery.
Providers across the country are experiencing a new “reality” in payment models where patients are presenting “Medicare PLUS” or “Cost PLUS” insurance cards, the latest tactic of self-funded, commercial employee benefit plans.
The first shots across the bow have been fired highlighting how benefits leaders need to pay as close attention to health benefits as they have been paying to retirement plans.
“The Number One Hidden Cost for Plan Sponsors is Embezzlement of Plan Assets” – Bill Rusteberg
This video is the second in a series and features a bold, fresh white board format to explain how a growing number of self-funded health plans are using Reference Based (or Cost Plus) Pricing to cooperate with area hospitals to agree on a pre-determined margin, thereby eliminating PPO networks.
Fear poor outcomes yield worse federal performance ratings…….punishable by less Medicare funding to hospitals with lower ratings…..
Tenet Healthcare has notified Humana that as of September 30, 2016, Tenet Healthcare facilities and physicians will no longer be participating in any Humana provider networks.
At a time when health care spending seems only to go up, an initiative in California has slashed the prices of many common procedures.
The next president could be dealing with an ObamaCare insurer meltdown in his or her very first month.
Aug. 10, 2016
Tips for Explaining Reference-based Pricing to ASO Employer Groups
Ms. Stinson had a 99 percent blockage of an artery, and her family was forced by the hospital to pay $25,000 before she could receive treatment, Ms. Stinson’s son-in-law told the Indy Star. A second blockage was discovered, and the hospital demanded $30,000 upfront before the second operation.
Big California Firms Take On Health Care Giant Over Cost of Care
UnitedHealthcare says in its suit that American Renal Associates billed out-of-network prices of about $4,000 per dialysis treatment, much higher than the $200 paid by the Florida Medicaid program.
Mr. Phelps of Mission Impossible
Your mission Jim, should you decide to accept it, is to review all documents to ensure best value for the McAllen Independent School District. As always, should you or any of your staff be caught or killed, the Secretary will disavow any knowledge of your actions. This pdf will self-destruct in five seconds. Good luck Jim.
It is clear that future Form 5500 reporting obligations will require more data, more resources and be subject to increased scrutiny by Federal agencies. Employer sponsors of group health plans should begin to evaluate plan documentation and the potential new disclosures required by Schedule J to ensure that each plan sponsor will be in a position to access such information and adequately communicate the new reporting requirements.
“The notion that insurance companies previously charged high premiums, or withheld coverage, from “high-risk” customers because they were evil and mean and greedy, but now Daddy Obama would make them see the error of their ways, was the dumbest and most expensive political fairy tale of the modern era.”
“The illusion of lower premiums today would be financed by higher tax bills tomorrow, and of course they’d never tell you they were raising your taxes to keep the ObamaCare scam floating. They’d tell you it was for bridges, or schools, or Social Security solvency, or something.”
Does your TPA use Deerwalk? Deerwalk is a state of the art system that will allow, among other things, a plan sponsor to compare PPO pricing against Medicare benchmarking on a real time basis. Plan sponsors, for the first time, can determine the real value of PPO “discounts”. Many will be shocked by the results.
By Jeff Evans
“I recently read an opinion piece that effectively summarized much of what many of us, in the health insurance and employee benefits business, have already figured out.”
By Molly Mulebriar
The best kept secrets of managed care are no longer the industry’s best kept secrets. The cat is out of the bag,
“The owner of Welldyn PBM and Continental Benefits has a vision to reduce health care spend in this country by 25%. With fresh capital from the sale of Welldyn, smart money bets Continental Benefits will become a national super TPA in short order. Before the Welldyne sale Continental Benefits was on a fast track. Now it will be nuclearized on an even faster track.” – Molly Mulebriar
Narrow Networks Fueling Surprise Medical Bills and Fights Between Insurers, Providers and Patients
Tenet believes it has reached an agreement in principle with the government to resolve the criminal investigation and civil litigation for $514 million.
“Woodrow Wilson once said “the seed of revolution is repression”. Healthcare has operated on a model outside of free market forces, where consumers have paid the price, literally for decades.
Is the future of American health care 430 miles offshore? American health care providers are watching closely and anxiously.