Is Your TPA Holding Out On You?

June 28th, 2016

avym

Is your third-party administrator holding out on you? Maybe you should check.

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Are You Ready for the New Face of Healthcare Payments?

June 28th, 2016

arlington

We’re pleased to announce our participation in Healthcare Payments Innovations scheduled for July 26-27, 2016, at the Chicago Hilton/Magnificent Mile Suites. We will be presenting a special feature presentation on Population Health and How Payments Must Evolve at 10 am on July 26 2016.

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Out-of-Pocket Inpatient Hospitalization Costs Up 37%

June 28th, 2016

mulebriar

Employers react to ObamaCare with cost shifting…………….Hospitals must upcharge to recoup……..the health care cost increase cycle never ends, it just gets worse – Molly Mulebriar

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BCBS – Taxes Are 17% of Administration Expenses

June 27th, 2016

tax1These results are excerpted from the Blue Cross Blue Shield edition of the 2016 Sherlock Expense Evaluation Report.

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Blue Cross Plans Hit Hard By ObamaCare

June 27th, 2016

bcbsenrollmentoffice

The nation’s Blue Cross and Blue Shield plans fared worse than publicly traded health insurance companies, with many plans losing hundreds of millions of dollars last year on individual policies sold under the Affordable Care Act.

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Health Care Strategies For Texas Political Subdivisions

June 26th, 2016

texascountiesSome Texas political subdivisions have reduced costs and improved benefits. Others have experienced the opposite.

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Texas Seeks TPA Services

June 25th, 2016

erss

Texas is seeking competitive proposals for TPA services for the state’s employee health & welfare plan.

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Doctors Hospital at Renaissance To Lose Transformative Leader

June 25th, 2016

dhr

The Lower Rio Grande Valley of Texas has produced many achievers over the years. Israel Rocha is one of them.

“Israel Rocha has been a transformative leader not only at DHR, but across the region,” Board Chairman Dr. Carlos Cardenas said in a prepared statement. “He has helped increase our community’s ability to care for patients and has successfully led the hospital during times of rapid change in the healthcare industry.”

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Selecting a Third Party Administrator

June 19th, 2016

tpa

Selection of a third party administrator (TPA) is crucial to the success of a self-funded plan. Criteria usually revolve around several factors including compatibility. Corporate philosophies of the employer and TPA should harmonize.

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A New App Could Help You Get Cheaper Medicine

June 19th, 2016

nerve

Amid an ongoing national debate over high drug prices, Blink Health hopes to drastically reduce what people pay for generic prescription medications.

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Glaucoma Cure?

June 17th, 2016

glaucome

The operation is designed to combat glaucoma, which can lead to permanent loss of sight.

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Cancer Cure?

June 17th, 2016

wayne

Experts said harnessing the body’s own defences was now giving “new hope” to cancer patients. The field – known as immunotherapy – is one of the most exciting in cancer treatment.

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Why Employers Should Unbundle Health Benefits

June 16th, 2016

brilliant

“It’s a myth that bundling all services through one integrated vendor saves money. What employers may save on administration, they lose in competitive rates, flexibility and transparency.”

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The Real Competitor For Insurance Brokers Is………………..

June 16th, 2016

competitionInsurance brokers fight a daily battle to gain new clients. It’s a tough business. You only get paid when you win, which is not that often. With an average closing ratio of less than 10% for group health insurance sales, one must wonder what is the main competition facing independent business men and women in the rough and tumble world of insurance sales?

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As Hospital Chains Grow, So Do Their Prices For Care

June 15th, 2016

hospitalmerger“Hospital chains that buy up other facilities, clinics and physician offices often tout savings and improved services from coordinating patient care and eliminating inefficiencies. The researchers found no evidence that any potential savings were being passed along to the employers, insurers and patients who pay for the care.”

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Want To Demystify Data Breach?

June 15th, 2016

logo_StuckeyEmail

Employers are facing significant risks from data breach but few are prepared for the consequences……

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Does Association Sponsored ASO Agreement Include Hidden Fees?

June 14th, 2016

money-trailA Texas based association sponsors a group medical plan for member firms throughout the state administered by a nationally recognized insurance carrier. As a service to their members, the association performs billing services on behalf of the carrier. Following the money is not always easy.

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Exclusionary Language & Undisclosed TPA Fees Attract Legal Scrutiny

June 14th, 2016

damnlawyers

Funds are withdrawn under the guise of a “savings” compensation structure as a means to cloak blatant misappropriation of funds…….fake discounts and fabricated contractual obligation………….

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Replacing Joints Faster, Cheaper and Better?

June 13th, 2016

hipreplacement1

San Patricio County recently paid $17,000 for complete knee replacement through their Cash Pay Plan Option managed by Asserta Health. This global fee did not only include hospital charges, it includes surgeon, assistant surgeon, anesthiologist, and other associated services.

Although the following article does not mention Cash Pay Plan Options, the reader should know Cash Pay Plans are the next evolutionary step for plan sponsors seeking fair and competitive health care costs. Asserta Health – www.Assertahealth.com

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Texas Health Care Privacy Law More Stringent Than HIPAA

June 12th, 2016

txhippaThe requirements of the Texas law are more stringent than those of its federal counterpart, the Health Insurance Portability and Accountability Act (“HIPAA”)………..HB 300 also requires any business in Texas that handles PHI to provide notification to individuals of a breach of their personal information.

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Responding to HIPAA Breaches

June 12th, 2016

holland

“Given the potential consequences, it is critical that covered entities and business associates respond appropriately to potential HIPAA breaches to avoid or minimize their liability.”

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City of Rockwall at Risk For Breach of PHI

June 11th, 2016

mulebriar

HIPAA violations are expensive. “The penalties for noncompliance are based on the level of negligence and can range from $100 to $50,000 per violation (or per record), with a maximum penalty of $1.5 million per year for violations of an identical provision. Violations can also carry criminal charges that can result in jail time.”

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TRS ActiveCare – What Will Texas Legislature Do in 2017?

June 10th, 2016

trsactivecare

By Bill Rusteberg

In a 2016 report, the TRS ActiveCare financials for 2015 should cause concern among Texas lawmakers. Because the state and district’s minimum plan contributions have not changed since 2002, active employee contributions have been raised each year to cover the projected expenses and claim costs.

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US Headed To Single Payer System Faster Than a Melting Raspa

June 10th, 2016

raspa1Obamacare was intentionally designed to fail because it was the only way they could force the country onto a federal system of socialized medicine. Now we’re all watching it happen.

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Hospital Chargemaster Insanity: Heeling the Healers

June 9th, 2016

mad

“I argue that the government needs to step in, not to take over responsibility for providing healthcare, but just the opposite, to eliminate the chargemaster pricing system…………”

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Operation Spinal Cap

June 9th, 2016

kickbacks

Kickbacks of $15,000 for each lumbar fusion surgery and $10,000 for each cervical fusion surgery..more than $580 million in fraudulent bills for spinal surgeries during the last eight years at one hospital alone……….

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Government Interference In Free Market Continues

June 9th, 2016

communism

Unelected government officials want to limit use of short-term health insurance in the United States to periods of three months or less.

Government hacks are also thinking about the possibility of banning the sale of critical illness policies and other policies that cover two or more specific diseases.

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Former Playboy CEO to run eHealth

June 8th, 2016

playboy2Flanders, a longtime media executive, has been an eHealth board member since 2008, and CEO of Beverly Hills-based media company Playboy Enterprises Inc. since 2009. In the past year, he has attracted attention by giving interviews to explain why Playboy magazine stopped running nude centerfolds.

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Healthcare Industry – Redistribution of Profits From Employers

June 7th, 2016

mulebriar

“It’s possible to deliver ”twice the healthcare, at half the price and 10 times the delight.” It might sound too good to be true but employers large and small are doing it and spending 20-55% less per capita on health benefits with packages that are better than what 99% of the workforce gets. It simply takes will.

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Road To Single Payer System – Poll Shows Citizens Want Government To Act

June 7th, 2016

beaver Entitlement Mentality Grows

“The report reveals many other aspects of health and health care, but the main message rings true: citizens want health care for themselves and other citizens.”

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Blue Cross Seeks 60% Rate Increase

June 5th, 2016

womencrying

Martita – Dewitt County Resident Reacts to proposed rate increase

Bad news for folks in Dewitt County, Texas. The only individual health insurance policy one can purchase there is one from Blue Cross. And, the only policy Blue Cross sells to the poor souls of DeWitt County is an HMO policy. Have cancer, forget about going to MD Anderson just down the road in Houston.

Our friend Martita, age 60, currently has a $6,000 deductible Blue Cross HMO individual policy with an annual premium of about $7,000. With a 60% increase she will pay about $11,200. If she gets sick, her out of pocket costs could be $17,200…………………

How about putting $17,200 in a tax free savings account and purchasing a $20,000 deductible health plan? No can do, that’s now illegal………………..

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Health Care Displaces Manufacturing as Tops in Jobs

June 5th, 2016

healthcarejobsJobs in health care, education, and social services have exploded. When Obama took office, just over 19 million Americans worked in this sector. Today, almost 23 million do.

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So It Happens Again

June 3rd, 2016

cookie

Michigan Sugar Co. filed a lawsuit Thursday against Blue Cross Blue Shield of Michigan, claiming the insurance company hid certain fees it was charging while administering employee health benefit plans.

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Taking PPO’s Into The 21st Century

May 31st, 2016

ppppooo

“In response to the continued relentless rise in health care costs, Insurers are taking a long, hard look at the value PPOs deliver versus their ability to contain medical costs.

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The Cost of Convenience

May 30th, 2016

ppoo

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Memorial Day 2016

May 29th, 2016

 rusreberg

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

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Billed Charges vs PPO Allowed Charges vs Cost Plus Insurance

May 26th, 2016

cost plus

By Bill Rusteberg

A random sampling of hospital / facility claims incurred in the Lower Rio Grande Valley, Texas (The Valley) illustrates the crazy world of health care pricing strategies.

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Dereliction of Fiduciary Duties Triggering DOL Investigations

May 26th, 2016
bernie

“The penalties for this type of fraud should be severe. All benefits leaders and their consultants should be overhauling how they manage care and cost, or risk the consequences. It’s particularly notable that the Department of Labor is now arguing that fiduciary dereliction in health benefits is rampant.” – Brian Klepper

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Annual Healthcare Costs For Families Hit $25,000

May 26th, 2016

As health care costs escalate, Cost Plus / Reference Based Pricing plans gain traction within the employer community…………….

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Moving Patient Payment Upfront

May 24th, 2016

highdeductibleHospital systems are beginning to screen patients in high-deductible plans for their propensity to pay. And for those who can, they are developing systems to collect in advance of care.

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New Approved FDA Drug Costing $1 Million A Year?

May 22nd, 2016

cigarette1

More and more employers are eliminating specialty drug coverage entirely. They really have no choice.

Imagine a small employer group of 250 employees assuming outright the risk of $1 million for Smoker Smith who now has lung cancer and is taking one of the new specialty drugs costing $85,000 per month. There is no way for the employer to continue his group medical plan. 

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The OPEC OF Healthcare

May 21st, 2016

dendy

Mike Dendy, MBA, MHA

“OPEC laughed at the US and the rest of the world when we complained that $120 per barrel oil was choking the life out of business and the public in general around the world.  Rather, they built ski mountains in their deserts out of the rest of the world’s money and threatened to drive oil prices even higher. ”  

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HealthSmart Announces New CEO of BridgeHealth

May 21st, 2016

healthsmart ge

(May 17, 2016)—HealthSmart announced today that Mark Stadler has been named CEO of BridgeHealth, effective June 1, 2016. Mark joined HealthSmart in September 2011 and has been the leader in our commitment to price transparency and empowering our members to become savvy healthcare shoppers.

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David Belk

May 19th, 2016

belk David Belk, M.D.

Hello. It’s time for another chapter on the many ways in which our health care system is a total mess.

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Surge In Drug Prices Zinging Some Health Insurers

May 19th, 2016

drug12

In an Oct. 5 report, The Wall Street Journal noted that prices for the 30 best-selling drugs last year had gone up an average of 76 percent since 2010 – eight times faster than general inflation.

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Plan Sponsor Guilty of Breach of Fiduciary Duties?

May 19th, 2016

horseSome plan sponsors hire a third party administrator to manage costs. Others hire third party administrators to process claims.

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Highmark Sues U.S. Over Affordable Care Act

May 18th, 2016

indiangiver

“All we’re asking is for the federal government to do what they promised” – David Holmberg.

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Low Cost Software Tool for Medicare Reimbursement Strategies

May 17th, 2016

rbrvsNeed a low cost Windows solution for creating and managing Medicare and other RBRVS based fee schedules?  Try RBRVS EZ-Fees…….

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Blue Cross Blue Shield Enrollment Office

May 17th, 2016

bcbsenrollmentoffice

Blue Cross mobile enrollment office – when gas was 17 cents, and health insurance was affordable

Playing Doctor

May 16th, 2016

playingdoctor

In a deep dark recess of today’s Federal Register, large corporations just quietly received permission to “play doctor” with their employees.

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Cash Pay Plans Make Sense

May 16th, 2016

flying

“Those who say Cash Pay Plans are pie-in-the-sky dreams are mistaken. If man can fly then so can Cash Pay Plans.”

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Nothing Makes Sense In Health Care Financing

May 16th, 2016

confused“In the world of group health insurance, in order to reach the best financial outcome, you often have to depart from the realm of logic, reason and actuarial principles.”

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BREAKING: High Court Punts On ACA Birth Control Battle

May 16th, 2016

birthconbtrol

Will Religious Institutions Be Required To Fund Against Their Will?

By Jeff Overley

Law360, New York (May 16, 2016, 10:35 AM ET) — The U.S. Supreme Court on Monday sent a long-running battle over the Affordable Care Act’s contraception mandate back to lower courts, directing the Obama administration and religious nonprofits to work out a compromise.

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Is HealthSmart For Sale?

May 13th, 2016

mulebriar

Is HealthSmart TPA for sale? Word on the street says it is so.

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Texas Gets 1115 Waiver Extension

May 13th, 2016

waiver

Hidalgo County health officials breathed a sigh of relief after the federal government last week extended the state’s 1115 Waiver program that provides hundreds of millions of dollars for health care services throughout the county.

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Multi-Tier Provider Networks

May 11th, 2016

curtain

“Multi-Tiered provider networks will work best if an employer creates their own proprietary network on a direct basis rather than rely on third party intermediaries. Here is how it would work: Area providers are invited to enter into direct agreements with ABC Fence Company. They are given three choices: Tier 1 – 100% of Medicare, Tier 2. 125& of Medicare and Tier 3. 150% of Medicare. Plan participants who use Tier 1 providers pay less out-of-pocket than if they had used Tier 2 providers. Using Tier 3 providers would take economic courage.”  – Homer G. Farnsworth, M.D.

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Rx Clawback Scheme Fleeces Customers

May 10th, 2016

clawback

Companies are charging copays that exceed the customers’ costs for their drug. Pharmacists call it a clawback – the company is essentially clawing back money from you and, our source tells us, you probably don’t even realize it’s happening. “They have no idea,” the pharmacist says.

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Austin Texas Pharmacy – “We Don’t Deal With Insurance Companies”

May 9th, 2016

MedSavers Pharmacy

Medsavers Pharmacy is a family owned and operated pharmacy in Austin, Texas founded in 2005 on the principle: “we don’t deal with insurance companies.”

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Wellcentive – Transitioning to Value Based Care

May 9th, 2016

wellcentive

Quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care.

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Shifting Risk To Hospitals & Physicians -Episodic Bundled / Fixed Pricing

May 9th, 2016

bundledpayment

As Medicare and private insurers continue to struggle with implementing accountable care organization- and population-linked payments, an increasing amount of attention is being paid to a less expansive but almost as complex method of shifting risk to hospitals and physicians: paying a fixed price for an episode of care, or bundling.

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Continental Benefits – The Purple Cow

May 9th, 2016

purple cow

Continental Benefits is one of the fastest growing TPA’s in the United States. Founded in 2013 this national TPA is committed to reducing health care costs 25% and more. And they are doing just that.

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Changes At Maxor

May 8th, 2016

maxorpharmacy

New CEO takes charge………….Maxor to exit correctional pharmacy services?

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Ruben Edelstein

May 7th, 2016

edelstein

By Bill Rusteberg

Ruben Edelstein practiced managed care in his own way. The son of immigrants, he ran a successful furniture business in deep South Texas. An astute businessman, he grew the business with locations throughout the Lower Rio Grande Valley.

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Anthem CFO To Resign

May 6th, 2016

resign“The timing of DeVeydt’s resignation may “generate uncertainty among investors until fully understood”

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Crazy World of Health Care Pricing

May 5th, 2016

southwestairlines

Why should you pay more to go to The Valley than the knuckle head sitting next to you?

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Aetna Selfies

May 5th, 2016

Enter Aetna, which is making its foray into this space with “Aetna Funding Advantage,” available to groups with as few as 10 employees.

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Businesses Opting For Freelancers To Dodge Government Punishment

May 3rd, 2016

freelance“Spurred by competitive demands for more agile organizations, the world of work is pivoting to a blended workforce………..nearly 40 percent of top performing firms already have more than 30 percent of their labor force composed of contract/freelance workers.”

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County Demonstrates Political Courage To Challenge Local Provider Community

May 1st, 2016

bot“The leadership of Botetourt County has, like many municipalities, been searching for innovative ways to reduce their health costs without increasing deductibles and co-pays to the members….”

Botetourt County, Virginia and San Patricio County, Texas have something in common – the political will to seek innovative strategies to rein in ever increasing, tax payer supported, health care costs for their employees. Challenging the status quo within their respective local health care community takes a rare political courage to prevail – Bill Rusteberg

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Affordable Health Care Is Just A Road Trip Away

April 29th, 2016

normanrockwel

People travel to visit family and attend business meetings, so why not travel for medical care?

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Specialty Drugs

April 29th, 2016
mulebriar
Bill, I have confirmed that a plan sponsor may exclude specialty drugs and remain ACA compliant – Molly Mulebriar

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Regulators Scrutinize Reference Based Pricing Plans – Phia Group To Host Webinar

April 28th, 2016

PHIA“Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now……”

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CVS Buys Target Pharmacies, Jacks Up Prices

April 28th, 2016

drug12

Walmart, Kmart, Safeway, and Kroger all charge $45 for the sildenafil, using the discount card, while Walgreens charges $450 and RiteAid $1,000…………

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Challenge To ‘Balance Billing’ Hits Hospital

April 27th, 2016

Virginia Lawyers Weekly

By: Peter Vieth April 22, 2016

For what may be the first time in Virginia, a judge has ordered a hospital to slash its “balance billing” charges by 75 percent to reflect the hospital’s usual write-off for uninsured patients.

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Specialty Drugs

April 25th, 2016
drugs1111111
QUESTION: Can a plan sponsor completely eliminate specialty drugs and remain ACA compliant?

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The ACO Delusion

April 25th, 2016

delusion

“We have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. …….The biggest sin the ACO’s commit is to distract from any real conversation about cost…………  “

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