“A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose………….”

When comparing insurance costs, using premiums does not present a realistic comparison; use rates. Divide the premium by the exposure (values, number of vehicles, cost new of insured vehicles, number of students).

By Bill Rusteberg

Lasers have been unfairly treated and it’s time to show a little respect!

The Transparency in Coverage Final Rule and Texas House Bill 2090 require disclosure of the negotiated rates with in-network providers and the historic allowed amounts paid to out-of-network providers, for all health plans available to employers.  Files containing this information for the plans covered are published on this page.

Murray was a most amazing character and ended up selling me life insurance….. at 27 years old!

Brownsville ISD board members debate the value of their health insurance broker at a Brownsville ISD Insurance Committee Workshop on May 13, 2020.

There is a difference between managing risk and servicing risk. Legacy health insurance brokers provide the later. New era health insurance brokers provide the former leaving TPA’s to service the risk.

By Josh Butler

I’ve got a brilliant idea….What is it? Let’s make buying prescriptions sooo complicated, no one will ever be able to understand it….

“Like a good neighbor, State Farm is there – and here and in my bed with my wife!”

Tesla dispute – top auto insurers writing off rather than repairing crashed Tesla EVs

by Mary Or 31 Jan 2023

Auto insurers have been writing off crashed Tesla EVs and sending them to salvage auctions instead, deeming many too expensive to repair.

(1) Crank up the printing presses and gift more money to health insurance companies to pay for out of control health care costs and (2) Gift stolen wages from working class Hyphenated-Americans to health insurance companies to pay for out of control health care costs.

“Bill provisions include making enhanced subsidies (OTHER PEOPLE’S MONEY) for Affordable Care Act Health Insurance Marketplace coverage, extended through 2025 in the Inflation Reduction Act, permanent; designating the second-lowest-cost Gold plan the benchmark plan upon which premium subsidies (OTHER PEOPLE’S MONEY) are based; and increasing the value of cost-sharing reduction (CSR) assistance for those with income between 100 and 250 percent of FPL (Federal Poverty Level) while expanding eligibility for CSR assistance to people with income up to 400 percent of FPL.”

Hiding Behind A Logo is a traditional American health care finance method of controlling the irrational correlation between cost of services and goods to end-user pricing while protecting ever increasing revenue streams from public display at the same time.

January 28, 2023

Barb Teron, a book buyer in Brook Park, Ohio, plans to delay her retirement because she is worried about Humira’s cost. Ms. Teron, who takes Humira for Crohn’s disease and colitis, has never had to pay more than $5 for a refill of the drug because her employer’s insurance plan picks up most of the tab. The cost, according to a pharmacy app on Ms. Teron’s phone, was $88,766 in the past year.

By Justin Nutt

A study in the U.S.A found that the most productive age in human life is between 60-70 years of age.

By Eric Kolenich

Hospitals are now required by federal law to publish the prices of mammograms, CT scans and hundreds of other procedures.

Medicare pays through the nose for services rendered by frugal doctor……….

“Daddy, who do you think you are, a doctor or an insurance company? Since insurance companies have always paid you and not your patients, doesn’t that mean you’re an agent of the insurance company?”

“Not any more son. Screw insurance companies! I work for my patients now” Dr. Doogood chortles.

Cash Pay Centric Health Plans are becoming a growing market trend, catching the attention of plan sponsors and government officials. The strategy is based on common sense, reason and logic applied to health care, something long missing from American health care financing.

Jack Sullivan who murdered John Bradbury, a railroad officer, during a gun fight, is seen smoking a cigar a few moments before he took his last breath in the lethal gas execution chamber at the state prison on May 17, 1936 in Florence, Arizona. / AFP PHOTO / ACME / – (Photo credit should read -/AFP via Getty Images)

“It seemed like the theme park ride vehicles were getting smaller, and I was getting bigger…..”

By Bill Rusteberg

Years ago a hedge fund operator called seeking information on Reference Based Pricing, a nascent but growing market trend at the time. He continued calling over the next six months to which I was happy to share my experience, both good and bad, with Reference Based Pricing.

Doug Aldeen takes a deep dive into Reference Based Pricing

JANUARY 23, 2023

Julianne calls up Doug Aldeen, ESQ an ERISA Healthcare Attorney and General Counsel to discuss the Reference Based Pricing (RBP) landscape, specifically how RBP has evolved over time.

J Patrick Rooney is considered by many to be the Father of Margin Based Pricing better known these days as Reference Based Pricing. Many believe his conclusion of what the “sweet spot” reference point should be still holds true today.

Turbocharge your chargemaster then offer payers 50% off double the price………..

Introducing RxPass from Amazon Pharmacy, a $5 prescription subscription that helps Prime members who take multiple medications save time and money

New Drugs for Weight Loss: What Plan Sponsors Need to Know

By Eileen O. Pincay, RPh

The latest generation of prescription drugs originally developed to help people manage their type 2 diabetes have been causing quite a stir for patients, health professionals and benefit plans, now that they’ve been approved and are being promoted to treat weight loss. Health benefit plan sponsors who are presently excluding weight-loss drugs from coverage are revisiting coverage rules because of the effectiveness and demand for these newer weight-loss drugs.

Employees Using Centivo Also Visited Primary Care Physicians More and Experienced Fewer Emergency and Inpatient Visits Than Industry Benchmarks

BUFFALO, N.Y. — Centivo, a new type of health plan for self-funded employers anchored around leading providers of value-based care, today announced key findings from its 2022 healthcare spend analysis derived from the Company’s flagship Partnership Plan offering. The findings reveal dramatic healthcare cost savings for Centivo’s employer clients (21 to 33 percent) compared to widely recognized industry benchmarks.

School is in session this Friday: Forward-looking #school leaders will join me in sharing the “secrets” to achieving world class healthcare while balancing their budget. Is your school district getting a passing grade on its #healthplan?

This webinar will feature forward-looking school and union leaders who have followed the Health Rosetta blueprint to achieve the Quadruple Aim (better health outcomes, lower costs and better patient & clinician experience) and no longer needlessly squander money on healthcare. And how you can replicate these solutions.

The last consultant quit, hence the RFP. That’s unfortunate because the previous consultant is widely considered among the best of the best in our industry.

Underwriting High Risk Plan Members

“Your employer can ask you for a doctor’s note or other health information if they need the information for sick leave, workers’ compensation, wellness programs, or health insurance” – Uncle Sam

Since its establishment over four years ago, Libra has changed the face of the insurance industry in Israel and has led moves such as a revolution in car insurance with a shift to a kilometer-based pricing model, pet insurance with online claims payment, and more.

“All-or-nothing clause”……….”Anti-steering clause”……….”Anti-tiering clause”……….”Gag clause”……….”Most favored nation clause”……….

With little formal training, a majority of health insurance brokers back in the day were simply spreadsheet artists………………………….

Blue Cross settles lawsuit for  about $2.67 billion……………………..

The Litigation

The process of the litigation was expensive as well as hard-fought. This is because it involved the creation of over 120 depositions, above 15 million pages, and more than a dozen pleas to dismiss claims of the plaintiffs. This is one of the unique kinds of an antitrust lawsuit and is said ‘historic’ in the court filing.

Educators Legal Liability Coverage (including employment practices)

Apex is a wholesale broker/program manager specializing in property & casualty insurance for public sector risks. We provide easy market access for local, independent agents to secure superior coverage at a competitive price.

“Although we will not disclose your identity without your express permission, it is possible that your identity may be discovered during an investigation of the matter reported because of information you have provided“.

Residents say Geraldine, Alabama is as close to the fictional idyllic 1960s TV town of Mayberry as you can get in real life. Located about an hour outside of Huntsville, the town of less than a thousand is the kind of place where everyone knows their neighbour and most people watch the Friday night football game.

“The nonrefundable administrative fee increased from $50 to $350. CMS says the case load of disputes is nearly ten times greater than initially estimated, resulting in the fee increase.

By Jody Bright

In answer to a question posed by a fellow on his Facebook page, what we each do I replied the following:

Where else in America can you make $1 million a year and play golf three times a week between vacations to Tahiti?

In 90 days, you could be seeing members of your new practice…………….

Members decide between Free Care vs Not-So-Free Care at the Point of Service…………………….

Segal’s analysis shows that in 2022 the most common stop-loss insurance deductible is $250,000, up from $200,000 in 2021………….For a stop-loss coverage plan with a deductible of $200,000, the median monthly per-participant premium was $85.80 in 2022, Segal reported. For stop-loss coverage with a deductible of $500,000, the median per-participant premium was $29.90.

Must self-insured plans provide essential health benefits?

Question: We understand that the Affordable Care Act (ACA) requires some health care plans to cover certain “essential health benefits.” Does that include our self-insured plan?

Crowded Waiting Rooms & The Rise of Direct Primary Care

“The percentage of U.S. physicians employed by hospitals, health systems or corporate entities grew from 62.2 percent in January 2019 to 73.9 percent as of January 2022.”

Skyward Specialty is a rapidly growing specialty insurance company, delivering commercial property and casualty products and solutions on a non-admitted and admitted basis.

All that we do on behalf of our clients is based upon these realizations:

1. If a loss is large enough, an insurance company will do everything possible to delay or avoid payment.

2. Claim adjusters and premium auditors work for the insurance companies – not for you. They aren’t your buddies. All ties, near ties or even questions go to the benefit of the insurance company.

3. a) Insurance companies and agents make money on what they sell; the more they sell, the more they make.
    b) If they don’t have available the particular coverage you need, you may never know you need that insurance until you have a loss.

January 11, 2023 / SkyQuest Technology Consulting Pvt. Ltd. / GLOBE NEWSWIRE / Yahoo / / Read Article

The pet insurance market was worth USD 7.1 billion by 2021 and is projected to reach USD 34.3 billion by 2028, with a high CAGR of 17.2% during the forecast period (2022-2028).

A concierge medicine practice, with revenues primarily based on annual membership subscriptions, thrives without the need to depend on reimbursements or expanded patient panels. Throughout its 20-year history the model has proven to be robust and resilient in the face of economic downturns, high inflation, sweeping healthcare reform initiatives, and most recently, the pandemic.

San Antonio’s Medical Industry Announces $37 Billion in Sales

More than 1 out of every 6 San Antonio-area workers are employed in health care, and about 50,000 net new jobs have been added in the last 10 years. Butler said the health care sector is easily the largest employer in San Antonio with 172,094 workers in 2015, a 13 percent increase from 2013.

Affordable Care Act Marketplace enrollment jumps 18% over last year

The Department of Health and Human Services recently announced that there has been an 18% increase in Affordable Care Act health insurance enrollment over last year’s numbers, in a major victory for the Biden administration’s efforts to expand access to health insurance.  

Yet Another Stash Of Classified Documents Discovered During Biden’s Colonoscopy

WASHINGTON, D.C. — The White House is on edge this morning after investigators revealed a fourth stash of classified documents from Biden’s tenure as Vice President was found deep ………..At publishing time, doctors had confirmed the colonoscopy also turned up another hard drive linked to Hunter Biden.

US Motorcycle Rallies Increase Organ Donations

MyHealthGuide Source: David C. Cron, MD, MS; Christopher M. Worsham, MD; Joel T. Adler, MD, MPH; et al, 11/28/2022, JAMA Network

In this cross-sectional study of 10,798 organ donors and 35 329 recipients of these organs from a national transplant registry from 2005 to 2021, there were 21% more organ donors and 26% more transplant recipients per day during motorcycle rallies in regions near those rallies compared with the 4 weeks before and after the rallies.

PAR Services Group Seeks to be a Family Home for a High-Quality TPA

MyHealthGuide Source: PAR Services Group, 1/13/2023

Nashville, TN – Cameron Dabir has formed PAR Services Group to acquire, grow, and permanently own a high-quality third party administration business.

“In economics, a moral hazard is a situation where an economic actor has an incentive to increase its exposure to risk because it does not bear the full costs of that risk. Anytime a party in an agreement does not have to suffer the potential consequences of a risk, the likelihood of a moral hazard increases.”

Vendor complains of a “simplistic” bidding process that failed to delve deep enough, said its proposal got 303 out of a possible 310 points, but that the state asked “superficial yes-or-no answers” on those 310 questions, treated each question as equally important and refused to accept any explanations from bidders.

“It’s not fair!” says Johnny “The Group Guy” Jones. “Government subsidizes individual policies but not group policies? That’s gonna put me outa business!”

Patients qualified for financial assistance; hospital sends them to debt collection instead

Nonprofit hospitals are required to provide financial assistance to low-income patients. Providence health system, however, did the opposite in many cases. Rather than ensuring that low-income patients received the financial assistance they were due, Providence hounded them to pay and sent debt collectors after them when they didn’t, according to a New York Times investigation. These actions were part of an official campaign to boost revenue called “Rev-Up” developed with help from corporate consultant McKinsey. The “Rev-Up” campaign directed employees to tell patients about financial assistance only as a last resort. The result: more than 55,000 patients were pursued by debt collectors when they should have been given a discount.

Value proposition: “Worry-free, time-saving and money-saving”, with the vision “to provide every enterprise with a harmonious workplace, every family with a dedicated doctor, and every user with a safe and healthy life”.

Rewarding incompetence puts New Jersey in the lead for the 2023 World’s Dumbest Plan Sponsor Award. Their crowning achievement to date, reaching the world’s highest pinnacle of incompetence, is the case where a hospital billed $674,856 for a patient’s hospital stay, but the state’s health plan paid over $2 million to the provider instead.

Relating to the establishment of a bundled-pricing program to reduce certain health care costs in the state employees group benefits program.

88(R) SB 358 – Introduced Version – Bill Text

88(R) HB 1239 – Introduced version – Bill Text (texas.gov)

BCBS of Massachusetts announces first-in-state value-based contracts with incentives tied to equity

The plan says the move is the first in the state and among the first in the nation to create a financial payment model rewarding providers for eliminating racial and ethnic inequities in care. 

Graph posted by Josh Butler on Linkedin

This graph tells you all you need to know about health care financing. There’s good money to be made working the spread (difference between the yellow line and blue line).