The Brownsville Independent School District, the largest employer south of San Antonio, is meeting tonight to award their group medical insurance program to United Health Care. The district is currently with Blue Cross & Blue Shield.
“Yes, and it’s beautiful! The client does not have a clue about this. It will not show up on the 5500 Form either! It simply is not disclosed at all to the client.”
“As people become more aware of the wide differences in quality and price, it’s inevitable that that information will be used in contracting with better performing providers and hospitals,” said Steve Wojcik, vice president oicy at the National Business Group on Health, which represents some of the nation’s largest employers.
Selling too good of a plan to the wrong people at the wrong time could lead to five years in prison.
Financially strapped district leaves +$500,000 on the table
The San Benito Independent School District, located in deep south Texas, has awarded third party administration services to the highest bidder in a recent Request for Proposal process. Estimated annual fixed costs for this 1,533 employee group is approximately $920,000. The lowest bid was $280,000.
This imaginary case study illustrates a common practice in the insurance industry to maximize revenue through deception.
Starting Sept. 1, a new law will allow physicians to get paid for seeing children over a sophisticated form of video chat, as long as the student is at school and enrolled in the state’s Medicaid program for the poor and disabled.
“La Joya ISD’s former insurance agent said trustees breached their contract and favored campaign supporters, according to a lawsuit filed against the district and trustees.”
“Ruth Villarreal served as the district’s insurance agent from 2006 until the board of trustees terminated her services in January. The district renewed her contract as recently as last year, months before a new board of trustees replaced her with Pharr-based insurance agent Bob Treviño.”
“Attorneys for Villarreal allege in the lawsuit filed this month in state District Court that trustees made the move because Treviño supported the Team Liberty slate in November school board elections. During the campaign, the lawsuit alleges, trustees “openly expressed their intention to exclusively award contracts to their supporters, including Defendant Trevino who was one of their main supporters.”
“You give enough money, it doesn’t matter how poor you perform, you’re going to get the contract — at least in La Joya,” said Javier Peña, an attorney for Villarreal:
La Joya ISD filed a counter lawsuit claiming governmental immunity…………………and lost on final appeal on August 21, 2015. Now Villarreal can move forward with her original pleading…………..and possibly another victory, either in or out of the courtroom.
“Benefits RFPs are universally awful and HR should abandon them…… RFPs are suited for buying a commodity, but not selecting a consultant……”
“The federal government will rent access to the Medicare network of providers effective January 1, 2016. Access fees, comparable to the private market, are projected to generate enough revenue to purchase health insurance for those who don’t want it, need it, or who can’t afford it.”
Texas-based independent insurance firm Higginbotham has hired Jonathan Sakulenzki as an employee benefits producer in McAllen, Texas.
“Insurance Agents are Free, Insurance Consultants are Not”
An email obtained by The Brownsville Herald shows TAC Health and Benefits Services Manager Bill Norwood was also in contact with Long during the request for proposals process, which the commission aborted last week.
“I am sorry about this outcome for you and your firm,” Norwood wrote Aug. 7. “It has been a pleasure working with you on this and we will be happy to recommend you in the future. I think we worked together well in developing option ideas for this county.
“We are going to provide them all the cost saving measures I told you about in our calls so we should see several areas with good savings.”
Brian Naiser, a TAC representative revealed the firm held more conversations with the county in the last two weeks than in the previous five years.
Hospital believes Aetna’s lawsuit is part of a “scheme to sue out-of-network providers throughout the nation to coerce them into financially burdensome in-network contracts with Aetna.”
“In America we have inequality due to income. Not being able to afford the 60 inch TV your neighbor has is annoying. Not being able to afford the platinum health plan your neighbor has, means that they will get better treatment and better access to healthcare than you.”
Nearly half of employers will be subject to the tax when implemented in 2018
The state has slashed any Medicaid rate that was higher than 145 percent of the commercial rate. While some rates wouldn’t change, others could be cut anywhere from roughly 30 to 90 percent……….
In a recent meeting with brokers, Blue Cross Blue Shield of Texas predicted that 80% of small-group business would be gone within five years. Seventy-percent of group medical in under-50 life groups will disappear and 90% of that in under-10 life groups. These small groups will migrate to self-insured plans or, in most cases, defined contribution arrangements.
Blue Cross in Dallas, for example, pays some doctors 10% less than Medicaid’s fee
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“The process has not been clear and concise. There has been a lack of transparency.”
Dealing With Patients Who Refuse To Pay
Handling patients with high deductibles health care plans and/or who refuse to pay in the ACA era is a growing financial risk for private medical practitioners.
“While reference based pricing is not new in many regions of the country, HMA is one of the first to offer this model in the Pacific Northwest.”
“Unelected federal bureaucrats issued 16 new regulations for every law in 2014 — that’s 3,554 new regulations compared to 224 new laws. ”
“These regulations severely hamper businesses, individuals, hiring and economic growth.”
Bitten by a cow? Pecked by a chicken? Burn due to water skis on fire? Yes, there is an ICD-10 code for each………………….
We are very happy to announce that the new expanded All Savers portfolio has been released beginning with 10-1 effective dates.
The Fox Group is among the leading healthcare consulting firms specializing in assisting physicians, acute care hospitals, long-term care providers, and a diverse group of other healthcare providers throughout the U.S. and abroad to achieve their strategic and operational goals. Read more…
Mr. Wolfgang Rusteberg has been a long-term care administrator in Germany for over 30 years, and an affiliated consultant with The Fox Group for over 10 years.
Automatic Data Processing Inc., the payroll- processing giant, will offer companies a new way for their employees to select health benefits, challenging firms like Towers Watson & Co. and Marsh & McLennan Cos.
By Molly Mulebriar
My Chief of Staff was breathlessly awaiting my return from lunch today. “Guess what, I found a heretofore unheard of PPO network that has great discounts! We should contact them!”
“Show me the evidence” I demanded.
“Where is the outrage over the lack of transparency for disclosing fees, charges, expenses and loads built into the healthcare system and health plans offered to employers by insurance companies ……..?”
“Why is no one demanding accountability for massive claim payment errors, overcharges, hidden charges and compensation, excessive fees, hidden spread pricing or medical errors?”
“Size matters less” The economic and risk equations are shifting for midsized and small employers weighing whether to self-fund their benefits claims.
“What we have is an industry phenomenon. TPAs and self funded plans complain about their networks all the time. How the discounts are bad, how you don’t have the ability to audit the claims, how the networks really work on behalf of the hospitals and not the plans. Everyone seemed to complain about them yet need them to attract clients that aren’t willing to go the reference based pricing route. You need a network to survive as I am told by every executive that has been in the industry longer than I have been alive.”
Establishing and maintaining reserves is important for self-funded clients. Reserves are estimated based upon a number of factors. As medical trend increases claim costs, one must adjust reserve factors to compensate for the additional risk exposure.
Grandma’s Self-Insured Dental Plan
By Darrell Pruitt, DDS
“As I read your political call for dentists to help expand Medicaid/Medicare dentalcare, currently administered by DentaQuest, it occurred to me that taxpayers deserve more transparency concerning DentaQuest – an increasingly popular but secretive destiny for tax dollars.”
Attorneys are accusing the company of deliberately inflating prices for generic drugs.
“We want to be daring and take on the biggest challenges that we can face,” he said. “We are no longer waiting for cures to come to use but we want to make that cure.”
New government accounting rules enable local officials to get unfunded obligations to retirees under control.
“Homo sapiens have always sought redemption. Today it is through data. Numbers have replaced Yahweh and Indra. But, just like the old gods were, numbers can be moody, arbitrary and, occasionally, downright unfair. Numbers are a human construct, after all.”
K&K Insurance Group, Inc., a subsidiary of Aon plc, has launched a new website at www.PrivateSchoolK12-kk.com offering K-12 student accident coverage. The website is designed for private, non-boarding K-12 schools and offers the ability to quote and purchase insurance online and receive coverage documents immediately via email.
Stressed Heath Insurance Broker Contemplates Future
“Brokers that are comfortable working on a fee-basis will be fine, but the majority of small and mid-size brokers still work on a commission basis, so this could be a real risk for them if they do not have the skill set or culture in their organization to engage clients on a fee-basis,” O’Connor says.
“The only hope is more hospitals/health systems take-risk based contracts as accountable care organizations and fill the national void with myriad local fee standing health plans who can give the remaining national carriers a run for their money and keep competition alive.”
Only massive bureaucracies with huge compliance and legal departments are equipped to deal with the approximately 40,000 pages of the Patient Protection and Affordable Care Act’s laws and regulations. It is crushing competition.
Every stakeholder was benefiting from the system, except one: the patient. In addition to the official costs of care and drugs, there was another price people had to pay: a fee known as “the envelope.”
EDINBURG – The Commission on Cancer of the American College of Surgeons granted three-year accreditation to the Doctors Hospital at Renaissance cancer program.
“The VA is funded with millions of dollars and billions of dollars but you will not pay providers? How is it the veteran’s fault that you are such an incompetent part of the United States government?” – Fred Rendon
Summary: The only way insurance companies can compete for business on the PPACA exchange is through lower rates. That is accomplished by paying providers less. Benefit design is mandated and therefore not a differentiator in plan selection.
DHR hopes to double size, but faces opposition from other local hospitals
Remember Xerox? How about Eastman Kodak? Both companies were pioneers in their industries. They were visionaries providing solutions by fulfilling previously unmet needs, creating new markets that did not exist before.
“Traditional models rely on a non-transparent contracting process in which insurance companies negotiate discounts off of over-inflated charges.”
Brownsville Independent School District (BISD) is seeking proposals for administration of the district’s self-funded employee health plan. BISD is currently with Blue Cross.
Chicago, IL, July 16, 2015 — Health Care Service Corporation (HCSC), the nation’s largest non-investor-owned health insurer, today announced several enhancements to its Blue Directions private exchange solution for large employers, available now for the upcoming 2016 benefit plan year.
Premiums are spiking around the country. Obama is in denial.
“Charging a fee for access to a group of health care providers has been a fantastic business. Low investment in capital assets, minimal labor costs and bountiful cash flows attract our country’s smartest investors. With margins above 60 percent, it is no surprise the Goldman Sachs of the world own networks.”
In health care provider-insurer contracts, three types of clauses inhibit price transparency: (1) non-disclosure agreements, or “gag clauses;” (2) anti-tiering/anti-steering clauses; and (3) most favored nation clauses.
New York Times reports that out-of-pocket spending on “most major birth control methods fell sharply in the months after the Affordable Care Act began requiring insurance plans to cover contraception at no cost…………….
“The provider, as is the case with many, initially told us that it was not interested in negotiating at all….”
Intel was rigorously managing its equipment suppliers but not its health care suppliers…….Intel decided it could use its purchasing power in markets where it had operations to influence health care players—care providers, health plan administrators or insurers, and other employers—to rise above their competing self-interests and work together to redesign the local health care system….
“Emergency departments are often more profitable than hospitals admit, as they are the source for roughly half of inpatient admissions. Patients admitted in emergency situations are rarely price-conscious, and revenue from ED admissions is often counted as part of subsequent inpatient stays. Furthermore, as non-urgent cases presenting in the ED are often relatively cheap to treat and well-covered by ED reimbursement rates, hospitals lack the incentive to redirect them to cheaper sites of service.”
“The U.S. Department of Health and Human Services has interpreted reference pricing as consistent with the principles of the Affordable Care Act when implemented by large, self-insured employers, and has adopted a salutary wait-and-see stance.”
Health insurance companies around the country are seeking rate increases of 20 percent to 40 percent or more, saying their new customers under the Affordable Care Act turned out to be sicker than expected.
Upon hearing the news, hordes of actuarys flock to liquor stores throughout the fruited plane seeking solace……………..“An actuary is a person who passes as an expert on the basis of a prolific ability to produce an infinite variety of incomprehensible figures calculated with micro-metric precision from the vaguest of assumptions based on debatable evidence drawn from inclusive data derived by persons of questionable reliability for the sole purpose of confusing an already hopelessly befuddled group of persons who never read the statistics anyway.”
The perception that BISD was screwed by HealthSmart over so called provider “pricing discounts” demonstrates common ignorance. This is understandable since the general public has no understanding whatsoever how our health care delivery system is structured.