Risk Managers – Thought Leadership on Health Insurance

Another Major Carrier Quits California

Allstate, one of the nation’s largest insurance companies, has joined State Farm in deciding to halt sales of property and casualty coverage to new customers in California, saying it’s too pricey to underwrite policies in the state which has seen thousands of natural disasters in recent years.

Vicious Kitty Cat Attack Costs $17,370

By Bill Hennessey, M.D. on Linkedin

I Tot I Taw a Kitty Cat – I did – I did!! And the Methodist Hospital TX ER bill was $17,370. Yes, for a cat bite.

Paul Wann

Operations Strategist, Paul Wann, Named Chief Operating Officer at HPI

MyHealthGuide Source: HPI, 5/31/2023

Westborough, MA – HPI, a leading national TPA of self-funded benefits, has tapped Paul Wann as their new chief operating officer. Paul will join senior leadership to drive the advancement of operations, automation, and programming. He brings over 30 years of experience in the industry, specializing in numerous areas including system configuration, member care, compliance, and analytics.

The Morales Store

If you haven’t been to Morales, Texas you haven’t lived yet. The Morales Store serves up the best hamburgers on the planet.

Texas City Fails To Control Health Care Costs

Attention Health Rosetta Advisors: Here’s an opportunity to bring sanity back to health care finance. This city’s reliance upon the BUCA’s has failed to control costs. Legacy brokers and consultants have failed to deliver desired results too. Doing the same thing over and over again is the definition of…………………..

The Doctor Can See You In Three Weeks (But The ER Doc. Can See You Now)

By Jeff Bernhard – Revive Health

This is an interesting read on wait times for doctor appointments, comparing the United States to other Developed Countries.

How Employee Benefits Will Shift in Next Three Years

For the longest time, most employee benefits programs have consisted of one-size-fits-all group policies for health and life insurance.

Brownsville ISD Considers Going To Bid For Health Insurance

TRS ActiveCare Publishes 2023-2024 Rates

TRS ActiveCare, a government health plan for Texas public school districts, has released rates for Plan Year 2023-2024.

Dave Chase – “So, How’s Your Health Insurance Business Doing?”

Warren Buffett said it all: “GM is a health and benefits company with an auto company attached.” In fact, it spends more on health care than steel, just as Starbucks spends more on health care than coffee beans.

Americans Can’t Afford Health Insurance Anymore But Employers Can Because……

How many American families can afford to pay $31,065 for family health insurance when 90% of working Americans earn less than $100,000 per year and 46% of working Americans earn less than $30,000 per year. After mortgage and car payments, rent, food, gasoline, clothing, beer & fajitas there is no money left for health insurance.

Dino Chavez Educates Board of Trustees On PPO Contracts

Dino Chavez, a Brownsville, Texas taxpayer, does an excellent job educating the Brownsville Independent School District’s (BISD) Board of Trustees in under five minutes on the power of managed care contracts and offers a common sense solution.

State Farm Quits California

State Farm General Insurance Company on Friday announced that it will stop accepting new homeowners insurance applications in California.
The company cited “rapidly growing” catastrophe risks like wildfires, “historic increases” in construction costs and a challenging reinsurance market.
“We take seriously our responsibility to manage risk,” the company said in a release.

Workers Compensation Insurance

We are now authorized to quote and bind Workers Compensation Insurance on behalf of Texas Mutual. In addition to Workers Compensation, HB 3752 authorizes Texas Mutual to establish and market a very different group medical program for employer groups of <250 employee lives.

Aldeen’s Sunday Morning Bathroom Read (Memorial Day Edition)

Profiteering Against the Public Interest: Privatization of Health Care by Unitedhealth Group

UHC was just smarter and recognized the direction of the market faster than everyone else i.e. privatize profit and socialize risk…

Memorial Day 2023

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart.

I knew little of my father’s participation in WW2 until after he died. Unlike veterans of today his generation didn’t talk much about it. Their quiet pride was enough, understood by all. The following recounts the Battle of Hatten in which my father was a participant. – Bill Rusteberg

Form 5500

Publicly filed, 5500 forms provide a wealth of information including disclosed (as opposed to undisclosed) insurance broker commissions.

A Paralyzed Man Can Walk Naturally Again With Brain and Spine Implants

Gert-Jan Oskam was living in China in 2011 when he was in a motorcycle accident that left him paralyzed from the hips down. Now, with a combination of devices, scientists have given him control over his lower body again.

Hidden Vendors & Third Party Risk Management

“Hidden” vendors can account for a significant volume of day-to-day transactions, accessing and storing vast amounts of plan participants’ personally identifiable information(“PII”) and personal health information (“PHI”). The delegation tactics used by employee benefit plan service providers place a premium on third-party risk management (“TPRM”) as a strategy.

Iconic Photo In Celebration of Memorial Day

Wait For Me Daddy!

“That’s probably the last time we were together as a nuclear family, as they put it today,” said Bernard in a recent telephone interview from his home. “We were never together again as a family after that moment.” – Warren “Whitey” Bernard (Blond headed boy in the picture)

TRS ActiveCare To Announce New Benefit Changes & Rates for 2023-2024

TRS ActiveCare is meeting next week to discuss new benefit changes and rates for the government’s health plan for Texas school districts. Will rates go down? Will benefits increase?

Epic Battle of The Blues

File this under “You Can’t Make This Stuff Up”

TRS ActiveCare officials are set to announce benefit changes and new rates next week. The battle to win Texas public school business will be off and running as districts gear up for school year 2023-2024.

Government Continues Aggressive Behavior Toward Plan Sponsors

[Guidance Overview] IRS Continues Aggressive Course of Proposing Penalties with Letters 226J “[If] the employer’s offer of minimum value coverage to an employee is less than or equal to the product of the federal poverty line and the affordability threshold for that particular year the employee cannot trigger an ACA penalty. This … is true even if the employer does not insert the federal poverty line affordability safe harbor code, 2G, in line 16 of the Form 1095-C…. [T]he IRS is apparently attempting to penalize employers under [IRC] section 4980H on grounds there is no basis for under the law.” MORE >> Accord

Sometimes Simple Decisions Are Hard To Make

By Bill Rusteberg

When things become political simple decisions benefiting everyone can become hard to make. A circular firing squad kills good ideas swiftly and effectively through “self destructive internal conflict and mutual recriminations.”

PBM Bill Advances in the Senate

While it is still relatively early in the legislative process, enactment of provisions in the current iteration of S. 1339 would pose significant impacts to entities across the prescription drug distribution chain………………

Why Can’t Plan Sponsors Pay Cash For Healthcare Services With QR Codes?

Yesterday Rhea Campbell, Co-founder ImagineMd sent a note that caught my interest:

“We are using QR codes to load plan funds to obtain cash pay pricing. We’re about to go live with a plan on 7/1 that has this option. We trigger the loading when we want to refer for imaging or mammogram for example. Cash pay for these services is slightly less than RBP so we’ll drive even more cost savings.”

Reference Based Pricing Benchmarks – Why Pay More When You Can Pay Less?

What’s the best Medicare pricing benchmark plan sponsors should use? Is it 100%, 120%, 150% or 200% of Medicare? Is there a material difference in balance billing issues between these tiers? The answer may surprise you.

Private Insurers Have Failed To Out Perform A Bunch of Bureaucrats

The over-arching truth – government has been much more effective than private insurers…….

Great Business Philosophy

Below is part of a contract we reviewed recently. The Agreement begins:

“The best work comes out of great relationships. Honesty, respect and gratitude are the keys to a great relationship and therefore we have an interest in treating each other with these values at all times. As much as legal documents are important, what truly binds us is our drive to do great work with great people and to develop a relationship of mutual respect and trust.”

Giving Employees A Choice Between Not-So-Free Care and………FREE CARE

A stand alone benefit option that can be added to any plan giving members a choice between free health care or not so free health care at the point of service.

“There Is No Such Thing As A $1 Million Claim”

Years ago I met a city manager who decided his city’s health plan could be administered in-house and stop loss was not necessary. “We will self-insure and win over time just like stop loss carriers do!” he said.

What’s Your NPI Number Doc?

The NPI Registry is a free directory of all active National Provider Identifier (NPI) records. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry.

BKS Partners

Since opening our doors in 2006, the BKS Holistic Protection™ model has produced double-digit growth and unprecedented client retention.

Liberty Bankers Final Expense Program

Why Use Liberty Bankers? Below are the bullet points that make Liberty Bankers an attractive carrier to write. Their underwriting and height / weight charts are extremely lenient to get your business issued quickly.

Managed Care Kryptonite Evicerates PPO Contracts

The government prohibits group health plans and issuers offering group health insurance from entering into agreements with providers, third-party administrators (TPAs) or other service providers that include language that would constitute a gag clause……………..

Warning: Viewer Discretion Advised – Video Contains Disturbing Content

Insurance Consultant Presents Findings To School Board

Warning: Do not watch this video if you have (a) High Blood Pressure, (b) Ulcers, or (c) Suicidal tendencies.

Best Kept Secrets Never Are

Ever told as a kid you couldn’t have something? So you were determined to find a way to get it come Hell or High Water?

Texas Legislature Considers FQHC Primary Care Access Program

Many small businesses in Texas have raised concerns that they cannot afford to offer traditional health insurance to their employees. As a result, many working families lack access to quality health care. One way to address this issue is through direct primary care.

Texas Considers Canadian Drug Importation

Texans of all political persuasions are fed up with the high cost of prescription drugs and they are about to do something about it.

Texas HB 633 Addresses Medical Price Gouging

If a restaurant charged one person $10 for a meal and charged another person $40 for the same order, it would be considered price gouging—and rightfully so.

Having Your Cake & Eating It Too

As compensation for its services under this Agreement, Gallagher will receive carrier commissions and/or direct fee owed by the Client, as set forth in the Compensation Disclosure Statement attached hereto as Exhibit B.

Aldeen’s Sunday Morning Bathroom Read

Sunday Morning Bathroom Read (Mother’s Day Edition)

“Gallagher would have a better chance of surviving a forest fire wearing gasoline underwear than trying to explain this…………..?

Community Health Plan Saves Money For Public Employees

Looking to save money, the district didn’t go to the “medical mile” for a solution but rather it veered down a small, dead-end, poorly-patched street in Ashtabula where inside a historic home a man and his team are trying to make history by patching the broken business of healthcare.

A HSA Cash Pay Centric Health Plan

Cash pay strategies are gaining traction in the market. Here’s a cash pay centric plan funded through individual, (but group paid?), Health Savings Accounts (HSA’s).

Astute Investor Moskowitz Is Bullish On Merck Stock

Jared Moskowitz bought Merck & Co Inc (MRK:US) on 2023-02-24

“People need to have confidence that policymakers are making decisions based on what’s best for the country, not what’s best for their stock portfolios.”

An Example of Critical Thinking

By Dean Jargo on Linkedin

When Americans sign up for traditional BUCAH-powered health insurance, what do most assume they’re getting? I believe the following objectives are top of the list for most folks:

HB 351

BACKGROUND AND PURPOSE

An arrangement under which an employer can offer both workers’ compensation insurance and a workers’ health insurance policy would allow employees and their dependents better access to health care. H.B. 351 seeks to provide for a workers’ compensation insurance company to contract with an accident and health insurance company to offer to employers a workers’ compensation insurance policy and a group accident and health insurance policy together in one packaged plan.

SB 1781 Considers Health Insurance Cooperatives For Texas School Districts

SB 1781 is expected to pass and take effect September 1, 2023. The bill lays out the framework for public school districts to set up and govern health insurance cooperatives for the benefit of their members.

Lynn Sold Her Life Insurance Policy For $180,000

Ask Lynn. She got $180,000 for her $500,000 policy. She realized her life insurance was getting more and more expensive each year. Her children were grown and financially independent, so there was no need to keep the policy. She read about life settlements and decided to sell her life insurance for cash.

Remodel Health Saves 30-50% Over Traditional Group Insurance

If you have clients on a traditional group plan, you can help them save more money while earning higher commissions with an ICHRA through Remodel Health.

Compassionate Care Plan™

A Risk Management Strategy Supported By The American Taxpayer

By Bill Rusteberg

The Compassionate Care Plan™ is a risk management strategy for self-funded employer groups providing an effective method of transferring high risk plan members to the individual health insurance market.

PPO Rep. Earned Easy Money Back In The Day

I always wondered how it was John (not his real name) seemed to be doing quite well working as a sales rep. for a rental PPO network. His wife didn’t work, he lived in an expensive neighborhood in a major Texas city, and was often vacationing at warm sunny beach resorts with plenty of umbrella drinks at hand. Life was good to John.

COLUMBUS LIFE INSURANCE COMPANY v. WELLS FARGO BANK, N.A

In February 2005, insurance broker Wesley Chesson submitted an application to Plaintiff Columbus Life Insurance Company (“Columbus Life”) for a life insurance policy on behalf of Dr. Earl Trevathan, Jr. The application, which was purportedly executed by Dr. Trevathan in Greenville, North Carolina, sought a $1 million policy with a $1 million rider, naming Dr. Trevathan as the initial owner and Dr. Trevathan’s estate as the initial beneficiary.

Texas Workers Compensation Is A Reference Based Pricing Plan

Reference Based Pricing is not new, it’s been around for a long time. Did you know that Texas Workers Compensation is a Reference Based Pricing plan?

El Paso ISD Believes PPO Network Saves Money

El Paso ISD uses the CIGNA PPO network. Other districts nearby use Aetna and Blue Cross. Of the three networks, which one offers the best prices?

A School District’s Secret Sauce To Solving Health Care

By Bill Rusteberg

Much has been written about the Raymondville Independent School District’s health plan over the past several years. Located in deep South Texas, this small rural school district has solved health care.

Ken Paxton – Risk Manager of The Year

Ken Paxton explains how he identified adverse risk factors, quantified expected outcomes, and put into place a strategy designed to mitigate potential losses.

Field Underwriting Aggregate Only Stop Loss Made Easy

Become A Bona Fide Field Underwriter In Under 5 Minutes!

High Plains Health Plan

Josh Butler, President Butler Benefits

Attention Texas Panhandle Employers!

On Tuesday, May 23, we are hosting an exclusive event to introduce High Plains Health Plan to regional employers, HR professionals, and Civic leaders at Hodgetown Stadium. The formal event will run from 3:00 to 5:00, followed by Happy Hour and networking immediately after.

Underwriting Self-Funded Medical Plans

By Molly Mulebriar

Underwriting a self-funded group medical plan involves assessing the risk and cost of providing health insurance coverage to a specific group of employees or members.

INSURANCE CODE CHAPTER 4151. THIRD-PARTY ADMINISTRATORS

Sec. 4151.002. EXEMPTIONS. A person is not an administrator if the person is:

17) a self-insured political subdivision

Joe Notches Up Guinness World Record

Insurance agent notches up Guinness World Record

91-year old receives recognition but is not yet ready to retire

Joe Sun Yung Tsu, a 91-year-old insurance agent, has been awarded a Guinness World Record for the “longest career as a corporate salesperson”, having spent 62 years and 238 days with Manulife Hong Kong.

First Circuit Holds Blue Cross Was Not a Fiduciary When It Allegedly Overpaid, Repriced, and Mishandled Benefit Claims

The court stressed that “[t]he fact that [Blue Cross] could make claim payments only with the Fund’s authorization, along with the fact that the Fund retained full control over the appeals process, weighs toward finding that [Blue Cross] lacked authority respecting the disposition of the working capital amount.”

How Breakthrough Technology Is Revolutionizing Medical Underwriting

For the underwriting process, the insurer receives detailed patient information at high resolution, from the questionnaire answers to results from specific lab tests. This data is used to completely personalize the insurance product, whether for pricing and actuarial purposes, underwriting, or management of the lifecycle of the policy and claims management. MPCheck supports a fully tailored approach to health insurance, and a completely different and more effective mode of risk management.

New Development In Virtual Hospital Will Make Being Healthy Easier

Sheba Virtual Hospital “Beyond” is making it possible for people to perform periodic medical examinations at work or at home.

Mandatory Government Contracts Benefit Low Performance Health Plans

This year, the Texas Legislature has the opportunity to repeal the anti-competitive, out-of-date state law guaranteeing Medicaid business to underperforming health plans.

Risk Management

Risk management is not a static or one-time activity. It is a continuous and dynamic process that requires constant learning and adaptation.

Remodel Health Says Ditch Your Traditional Health Plan & Replace It With………

Ditch your traditional group health benefits once and for all………………..

Researches Discover Mental Health Cure

Descendants of the Greatest Generation are definitely not Chips Off The Old Block……

Confessions of A Hospital CFO

Hospital Finance 101: Understanding the Cost of Full-Service Healthcare in Pullman, WA Program by: Steve Febus, Pullman Regional Hospital Chief Financial Officer Learn more at

http://www.pullmanregional.org/transp…

Small Texas School District Solves Health Care

What a turnaround story…This is the poorest and one of the smallest school districts of over 1200 in Texas…………….

Which Side of The Table Does Your Broker Sit?

Fee based independent insurance consultants are comfortable within their own skin, confident their relationship with their client is founded on shared philosophies and goals. They know if they don’t produce acceptable results, they are replaceable. They’re good with that. They sit on the same side of the table as their client on equal terms.

Why Consultants Should Just Say “No” To RFP’s

“Benefits RFPs are universally awful and HR should abandon them…… RFPs are suited for buying a commodity, but not selecting a consultant……”

Magic Dust Underwriting

A warehouse filled with Magic Dust has been discovered in a remote area of DeWitt County. Governor calls upon school districts to remain calm………………