Health Insurance Agents Turn To Begging

August 24th, 2016

beggar

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…………………

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Price Gouging Continues – Deep Pockets Targeted

August 24th, 2016

pockets

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.

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Health Care Pricing Transparency Drives Competitive Free Market

August 24th, 2016

albetross

Consumers Flee High Cost Hospital 

Texas General Hospital in Grand Prairie may be struggling to attract patients for elective services after a report named it the most costly hospital in the state, reports Dallas Observer.

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Largest Physician Owned Hospital in USA Expands Foothold

August 22nd, 2016

 

dhr12

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.

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Who Is Getting Rich from the Price of Prescription Drugs?

August 21st, 2016

moneyrich

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.

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PBM Exposes Industry Secrets on Specialty Drugs

August 21st, 2016

shellgame1The audience was aghast to learn that a specialty drug for Hep.C. earned PBM’s a 45% commission for one course of treatment………..

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Pascal Metrics Provides Patient Safety Analytics

August 21st, 2016

pascalmetrics

Pascal Metrics is the field leader in measuring and improving patient safety through advanced Patient Safety Analytics (PSA).

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Comrade Bernie Touts Medicare for All

August 18th, 2016

communitsSen. Bernie Sanders says the ability of Aetna to disrupt the public health insurance exchange system in 2017 by withdrawing from 11 states’ programs shows why letting private companies sell health insurance is a bad idea.

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BMA TPA Announces New Website

August 18th, 2016

bma

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.

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Employers Look To Direct Health Care Contracting

August 17th, 2016

middleman1

Cutting out the middle man………………………..

Industry denials notwithstanding, reducing healthcare costs is fundamentally against nearly every healthcare organization’s perceived economic interests.

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Specialty Drugs – What Can A Plan Sponsor Do?

August 16th, 2016

bulletSpecialty drugs are bankrupting self-funded health plans. 

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Drug Crazed Elderly – America’s Other Drug Problem

August 16th, 2016

elderlydrug

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.

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Texas School Districts – Insurance Fraud & Political Empowerment

August 15th, 2016

favor

“No problem Joe, I’ll make a call for you”

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Why You Can’t Find The Doctor You Need

August 15th, 2016

sorry

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.

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Health Care Statistics Between USA, England & Canada

August 14th, 2016

kinggeorge

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.

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Keeping Up with New Payment Models: “Cost Plus” or “Medicare Plus”

August 14th, 2016

newrealityProviders 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.

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CFOs & HR Execs Facing Millions In Personal Liability Over Health Plans

August 14th, 2016

fiduciaryThe 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

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Video Helps TPAs To Market Reference Based Pricing Plans

August 14th, 2016

rbpricingThis 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.

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Hospitals Disposing of Organs, Refusing Transplants

August 12th, 2016

transplantorganFear poor outcomes yield worse federal performance ratings…….punishable by less Medicare funding to hospitals with lower ratings….. 

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Tenet Healthcare Terminates Humana Contract

August 11th, 2016
'You're fired, eliminated, laid off, let go, downsized, terminated ...'

‘You’re fired, eliminated, laid off, let go, downsized, terminated …’

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.

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How Common Procedures Became 20 Percent Cheaper for Many Californians

August 11th, 2016

amazing

At a time when health care spending seems only to go up, an initiative in California has slashed the prices of many common procedures.

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Next President Faces Possible ObamaCare Meltdown

August 11th, 2016

thatcher

The next president could be dealing with an ObamaCare insurer meltdown in his or her very first month.

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BCBS Offers RBP Selling Tips

August 11th, 2016

Aug. 10, 2016

Tips for Explaining Reference-based Pricing to ASO Employer Groups

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Call To Action – Help Expose The Truth – Whistle Blowers Welcome

August 9th, 2016

mulebriar

Insurance insiders know the truth about undisclosed compensation paid to insurance agents, brokers and consultants by the BUCA’s. It is the industry’s best kept secret ( Health Insurance Consultant’s Best Kept Secret)

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Patient Held Hostage By Hospital Over $53,000 Bill

August 8th, 2016

hostage

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.

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Big California Firms Take On Health Care Giant Over Cost of Care

August 8th, 2016

boxing

Big California Firms Take On Health Care Giant Over Cost of Care

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Scheme Switches Medicare/Medicaid Patients to Private Insurance

August 7th, 2016

whydidntUnitedHealthcare 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.

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McAllen ISD To Award TPA Contract – Proposed ASO Agreement Made Public

August 6th, 2016

missionimpo

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.

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Proposed Form 5500 Changes To Increase Plan Sponsors Obligations

August 6th, 2016

shocked

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.

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Most Expensive Fairy Tale of The Modern Era

August 6th, 2016

fairytale

“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.”

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Deerwalk, A Powerful Tool For Plan Analytics

August 5th, 2016

Yes_Baby

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.

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The ACA Medical Loss Ratios – “COST-PLUS” Health Insurance in Disguise

August 4th, 2016

evans

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.”

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Managed Care – Cat Is Out of The Bag

August 4th, 2016

catoutofbagBy 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,

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Welldyn Sold – Will Super TPA Benefit?

August 4th, 2016

mulebriar

“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

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Narrow Networks = Balance Billing

August 4th, 2016

angrydoctor1

Narrow Networks Fueling Surprise Medical Bills and Fights Between Insurers, Providers and Patients

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Tenet Increases Reserve To Settle Kickback Allegations

August 3rd, 2016

tenetTenet believes it has reached an agreement in principle with the government to resolve the criminal investigation and civil litigation for $514 million.

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HealthCare’s “Brawl For It All”

August 2nd, 2016

boysfighting

“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. 

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BCBS of Texas To Drop 470 Kelsey-Seybold Physicians

August 1st, 2016

fired

Blue Cross and Blue Shield of Texas will sever ties with Houston-based Kelsey-Seybold Clinic, putting approximately 100,000 patients out of network with the providers’ physicians, the Houston Chronicle reported.

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Shrinking Networks

August 1st, 2016

freshberries

Reid Rasmussen

Insurance carriers know it. If you build self-funded plans, you know it. There are ways to reduce plan costs while ‘hiding’ the reduced benefits. One of the rapidly growing methods is to shrink the provider network.

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Are Insurers Ditching PPO’s?

July 31st, 2016
ppooInsurers that have been offering PPO plans in the healthcare marketplace appear to be cutting back on the number of offerings or eliminating PPOs from the marketplace altogether, leaving consumers with fewer options. Is this becoming an industry-wide trend?

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Offshoring American Health Care: Higher Quality At Lower Costs?

July 30th, 2016

medicaltourism

Is  the future of American health care 430 miles offshore? American health care providers are watching closely and anxiously.

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Ex-UnitedHealth CEO Raising $81 Million for New Insurance Startup

July 28th, 2016

brighthealth

Bob Sheehy, the former CEO of CEO of United Healthcare  UNH 0.76% , is back with a new startup called Bright Health.

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BCBS Over-Payment Practice Dealt Death Blow

July 28th, 2016

morgue

This might be the first time in US healthcare history that a federal ERISA court grants a permanent injunction against a violative insurance company or health plan.

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Is Medicare +25% Reasonable?

July 28th, 2016

rooney

Is 125% of Medicare a reasonable reimbursement rate? Patrick Rooney thought so back in the 1980’s. Many believe it still is.

Several of the BUCA’s pay less than that for out-of-network provider pricing. We have seen some of the BUCA’s pay out-of-network hospitals 105-110% of Medicare. 

Our book of business primarily employs reference based pricing strategies paying hospital / facilities 120% of Medicare since 2007. – Bill Rusteberg

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Federal Audit Police Poised to Pounce & Punish

July 27th, 2016

helpgovAn official blasted the Office for Civil Rights for going too easy on the covered entities……..Next round of audits to be tougher and could lead to legal action…….

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Insurance Companies & Private Hospitals Facing Off In Houston

July 27th, 2016

toodamnhigh

Your Billing Is Too Damn High!

According to the Houston Chronicle, at least a dozen lawsuits have been filed in the city in recent years over what insurers claim is an incorrect practice: private hospitals offering patients lower rates that compete with “in-network” facilities by billing the insurance company more.

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DoctorGlobe Launches Nation’s First Online Hospital Shopping Platform

July 27th, 2016

likw

DoctorGlobe launches first online hospital-shopping platform to help self-funded employers discover better care for less featuring an algorithm that ranks 120+ surgery procedures across 2,800+ hospitals nationwide by quality, distance and price.

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Healthcare’s Biggest Lie

July 26th, 2016

pinnochio

“PPO networks are a quaint artifact of pricing failure……….if you study the numbers, it is impossible to not come to the conclusion that healthcare is the single greatest threat to America. As Klein pointed out, inflated pricing is public enemy #1.”

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Captain Kirk To The Rescue

July 25th, 2016

startrek

Hospitals, Physicians, Big Pharma and Insurance Companies have been dictating pricing and making the rules continuously for decades………..The rigged game of health care is similar to the Kobayashi Maru….

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Health Insurance Consultant’s Best Kept Secret

July 24th, 2016

bribe1“All (insurance) companies offer bonuses” to consultants. “It’s a way to sell the product and saves them from hiring 20,000 agents,” – Joe Grady

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Government To Block Aetna, Humana, Cigna, Anthem Mergers ?

July 21st, 2016

amazingThe Justice Department is preparing lawsuits to block two giant health insurance deals, according to a person briefed on the matter, continuing a spate of antitrust actions in a whirlwind year for mergers and acquisitions.

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The PPO Claim Re-Pricing Charade

July 20th, 2016

priceisright

Plan sponsors want to know which PPO network has the best and lowest costs. They hire consultants to find out.

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University Must Pay $2.7 Million HIPPA Settlement

July 19th, 2016

cloud

This settlement also could reflect an ongoing “raising of the bar” by HHS where HIPAA compliance is involved……………University did everything right except relationship with cloud vendor………

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The Next Innovation In Controlling Healthcare Costs

July 18th, 2016

catchingup

Many Texas employers have been using reference based pricing strategies since 2007. These early adopters have enjoyed great success in containing medical costs. All have succeeded in beating medical trend, maintaining static costs while improving benefits.  

Markets sometimes take time to adapt, as the status quo is always in the best interests of vested interests, including insurance brokers, carriers, TPA’s, hospitals and managed care organizations. Now we are seeing reference based pricing strategies gaining rapid market growth. For example the state of Montana adopted a reference based pricing for the state’s employees just this month. – Bill Rusteberg

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Covered Entities Now Must Have Accessible Websites

July 18th, 2016

raycharles

There has been a proliferation of ADA lawsuits alleging that websites are not accessible to the blind or deaf. …….Target pays $6 million punishment fine to government…………..

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UHG Responds To Belk?

July 18th, 2016

belk

I wanted to update everyone on what I thought was a rather curious comment I found posted on the blog I wrote two weeks ago about United Health Group. You might remember that, in the blog, I questioned whether United Health had really lost money on the ACA exchanges last year. See – Belk Digs Into UHC Finances – Questions Motive To Leave ACA Exchanges

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Politician Attorney Fights Insurance Companies

July 18th, 2016

hinojosa

Politician-Attorney Fighting For Plaintiff’s Lawyers

It’s all about protecting one’s profession and not at all about protecting consumers. It’s all about government taking care of people who are too stupid to take care of themselves. It’s all about government interference in a free market economy where sellers and buyers choose who to do business with. 

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Transparency In Healthcare

July 17th, 2016

brickwall

“This is as clear as I can make it, if you work with one of the big healthcare carrier (ASO) companies there is no transparency and there never will be.  “ – Mike Dendy

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Insurers Pushing For Higher Rates To Pay Health Care Partners

July 17th, 2016

dontt

“Insurance companies continue to look out for their medical provider partners. Secretive managed care contracts between these conspirators continues to assure annual increases in reimbursement rates, year after year. “

“It’s true that 90% of health insurance rates go to pay medical caregivers. The more providers charge for their services the higher the rates need to be. The only method to reduce health insurance costs is to reduce fees paid to medical caregivers as the State of Montana has done this year under the state employee health plan. It’s that simple” Homer T. Farnsworth, M.D.

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Plan Sponsors Beware! Are You Next?

July 16th, 2016

flores 

Mike Flores

“According to industry experts, more and more CEO’s, CFO’s and Plan Administrators are exposed to tremendous liabilities due to poorly managed or “Head in the Sand” monitoring practices. As we have written about and predicted, this is evidence of the growing trend of self-insured health plans being exposed to tremendous liability by TPA’s.”

“These cases also illustrate an ironic twist, in many cases, the ASO agreements prohibit the plan from auditing the claims that the TPA’s are paying on behalf of the self-insured plan, which on its face, seems to be a remarkably absurd clause that any plan sponsor would agree to sign.”

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Have You Received Your Thank You Letter From BCBS Yet?

July 16th, 2016

mother

A billion dollar gift and no thank you note is something mother would have never approved.

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TPAs Developing Innovative Strategies To Control Health Care Costs

July 16th, 2016

crap

KGA has identified providers that offer transparent, greatly-reduced, all-inclusive cash prices. These providers allow KGA to utilize this pricing because the claims are paid quickly and at 100%. Plan participants utilizing a Kempton Premier Provider for a covered medical procedure benefit by incurring no out-of-pocket costs and the plan receives substantial savings. It’s a “win-win” for all parties involved.

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Montana Adopts Reference Based Pricing Strategies

July 15th, 2016

montana

Montana adopts reference based pricing model for state employees. Will other states follow?

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Insurance Consultant Sentencing Postponed to Sept. 28

July 14th, 2016
haff

William Haff

A 46-year-old San Antonio independent insurance consultant William O. Haff is facing up to five years in federal prison after pleading guilty to his role in a kickback/bribery scheme earlier this year involving local school district insurance plans. Original sentencing was scheduled for July 13 but has now been postponed to September 28, 2016.

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Insurance Consultants Are Biased

July 14th, 2016

mulebriar

“The last category of independent insurance consultants are those that are never comfortable outside their insulated environment. They like the warm and fuzzy feeling of staying at home in a loving environment with Mommy.”

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Trojan Horse: Obama Embraces ‘Public Option’ on Obamacare

July 13th, 2016

trojan

Critics of Obamacare warned in 2009 and 2010 that the so-called “Affordable Care Act” was merely a “Trojan Horse” that would eventually to a complete government takeover of health care. For that, conservatives were mocked and demonized.

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Reference Based Pricing Market Blitzkreig

July 11th, 2016

blitzkreig

“As more employer groups have adopted this strategy, hospital and provider groups have begun to take notice and push back. Therefore, the future of these plans is still uncertain” – Scott Aston

Editor’s Note: The author is mistaken. The future of Reference Based Pricing plans is not at all uncertain. PPO’s are going away, replaced with common sense and prudent business practices. Plan Sponsors are on to the PPO game and don’t like what they see. They are mad as hell and not taking it anymore.

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Dear Mr. Slavitt, Please Come Visit My Office

July 11th, 2016

dochouse

Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis……………

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A Review of 4 Key Cases & New Laws Affecting Employers

July 11th, 2016

coned A range of legal decisions and fact sheets released by government organizations in recent months are expected to have an impact on employee benefit plans. In the wake of these cases and related guidance, advisers and employers should review their policies on topics such as cash-in-lieu of benefits, pregnancy discrimination, health questionnaires and arbitration agreements.

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CIGNA Administered Health Plan, DHL Express, Sued for Embezzlement Scheme

July 10th, 2016

dhl

A scheme to withhold, embezzle, and convert ERISA plan assets through a pattern of fraudulent benefits transactions and prohibited self-dealing……..Practices that may be endemic to the industry as a whole?

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No, We Won’t Treat You Unless You Pay More!

July 9th, 2016

mulebriar

By Molly Mulebriar

When a hospital refuses to accept a patient because their health insurance plan limits allowed charges to 120% of Medicare reimbursement rates, and instead offers to discount their charges by 15%, one wonders how much more will the patient be asked to pay.

Of note is the hospital routinely accepts 100% of Medicare from Medicare patients.

Since hospitals never disclose their charge master rates, agreeing to pay in advance for medical services on the basis of a 15% discount off an unknown number makes no sense at all. We don’t agree to purchase any other goods or services on that basis so why would we do so for health care?

Fortunately in Texas, there is a law that requires hospitals to provide a cost estimate in advance of services rendered, unless the charges are for immediate emergency care.

According to the Texas Insurance Department website “Texas law gives patients the right to request estimates of charges. Doctors and other providers and health plans have 10 days to give you the estimates.”

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Mayor Looks To Take On Hospitals Health Care Pricing

July 8th, 2016

soglin

Mayor wants hospitals to reveal the actual cost of providing care so the city can determine if prices are too high.

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Balance Billing Is A Plan Sponsor’s Best Friend

July 7th, 2016

jet

By Bill Rusteberg

“Balance billing only occurs when purchasing  goods or services without asking  the price.”

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Belk Digs Into UHC Finances – Questions Motive To Leave ACA Exchanges

July 5th, 2016

belk

“United Health Care announced last fall that they would be pulling out of the ACA exchanges because the Obamacare policies were costing them too much money. I thought that was a curious announcement since, according to their financial statements from last year, they appeared to be doing quite well.”

“I’m really starting to wonder if I’m the only person who ever checks financial statements” – David Belk, M.D.

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Super TPA – The Purple Cow of Health Care

July 4th, 2016

purple cow

Continental Benefits has brought some of the brightest and most entrepreneurial minds in healthcare together with a focus on not just stepping outside of the box, but tearing it down and building something entirely different……..

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