ERISA Class-Action Litigation over Fees in Health and Welfare Plans

December 13th, 2018

A potential mine field for health-plan fiduciaries involves failure to ensure that plan participants pay only ‘reasonable’ fees for services, including co-insurance and deductibles…………..

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Sales Bonus or Bribe?

December 13th, 2018

“The employer has no one — not the carrier, the broker, the third party administrator, the pharmacy benefit manager, the hospital or the doctor — sitting on their side of the table, with a shared incentive to lower healthcare cost.”

– Nelson Griswold, president of Bottom Line Solutions in Nashville, Tenn.

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I Own You – Do What I Say or I’ll Break Your Legs!

December 12th, 2018

Pssst, Godfather, Bill Is Attempting To Move Our Business!

“Tell Bill I’ll make him an offer he can’t refuse………………………………………”

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Rebates!

December 11th, 2018

Rebate programs do not save employers money…………………………..

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Handling Health Claims: Traditional Carriers vs TPAs

December 11th, 2018

“For the lion’s share of claims, the TPA is still leasing a large carrier network in order to secure the negotiated discounts with doctors and hospitals. But … there are some services for which the carrier’s network rates are egregiously high — and for those services the TPA will simply apply Medicare reimbursement levels instead….”

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Sierra-Berkshire Associates

December 11th, 2018

Affordable Care Act Increases Need for Actuarial Services……………

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What Is AWP?

December 11th, 2018

It is an elevated drug price that is rarely what is actually paid……………So why use it?

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Rare View Behind The Curtain

December 11th, 2018

Drug prices are difficult to determine for patients. Drug wholesalers, distributors, healthcare providers, pharmacy benefit managers and pharmacists keep prices hidden from the public. Until now…………………………..

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That’s Not What We Were Told!

December 10th, 2018

Hermann Ebinghaus

How effective are employee health insurance benefit meetings? Or are they a waste of time?

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Texas: Short Term Medical Plans Under Attack

December 9th, 2018

In January, the 86th Texas Legislature will convene in Austin. Hopefully, they will address expanding health coverage in Texas, prohibit short-term coverage from discriminating based on health status, and limit the maximum time an individual may be enrolled to less than 364 days………….

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Deep South Texas Faces Unique Health Care Challenges

December 9th, 2018

25% of the population in deep South Texas receive free health care. Known as The Valley, the region has unique health care and economic challenges including a high diabetes rate, high poverty rate, and heavy dependence upon government and health care jobs…………………

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Tyler Man Connected To PBM Kickback Scheme

December 8th, 2018

Tom Slack, of Tyler, received more than $1.5 million in illegal kickbacks………………

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Texas Insurance Consultant Forfeits License

December 8th, 2018

Convicted Texas insurance consultant William Haff forfeits insurance licenses……………accepted bribes to steer public school business to insurance broker………………

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Health Care Sharing Memberships Top 1 Million

December 8th, 2018

A million Americans — a number that is growing — have rejected medical insurance for membership in one of the 104 known and active Health Care Sharing Ministries in North America…………………………….

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Decades Old BCBS Love Hate Relationship Continues……….

December 8th, 2018

Hospital administrators throughout Texas say the insurance company is using “strong-arm” tactics to push unfavorable contracts……………

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Guaranteed Cost Stop Loss Insurance

December 8th, 2018

Guaranteed cost stop loss insurance for today’s environment……….

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RxReins

December 8th, 2018

Bringing financial stability. Ensuring peace of mind.

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Plan Sponsors At Risk For High Fees – Breach of Fiduciary Oversight

December 8th, 2018

 

“Health-plan participants could conceivably choose to challenge health-plan fees with general fiduciary-breach claims. In fact, it is reasonable to expect that such claims will be made against other health-plan sponsors, given that plaintiffs’ firms have begun to solicit potential class representatives and request health-plan fee information from employers.”

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Communist China Adopts Free Market Medical Costs Strategy

December 7th, 2018

China embraces competitive bidding instead of price fixing?………….A free market approach in a communist country?…………………….Mao Zendong must be rolling over in his grave these days……………..Meanwhile back in the United States Cloned Zendong’s move forward pushing their Cultural Revolution with fervor……………..

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Wallet Biopsy Determines Prognosis

December 7th, 2018

Patients must be first class fund raisers – their lives depend on it…………………………

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Here’s To The Crazy Ones……………….

December 6th, 2018

“Here’s to the crazy ones. Misfits, rebels, troublemakers. They are not fond of rules. They have no respect for the status quo. They change things…………………….”

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Turd Polish Season

December 6th, 2018

Most traditional benefits brokers are wrapping up Turd Polish season (aka Open Enrollment). You know, that process of trying to make the “pay more, get less” benefits discussion that happens every year.

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Get Your Healthcare Before It’s Too Late

December 6th, 2018

If you’re currently without healthcare for next year or are in search of a new program heading into 2019, you need to know that the deadline to purchase health insurance through the government Exchange is December 15.

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Pigs To The Rescue…………………

December 6th, 2018

Pig hearts could soon be tested in humans after scientists pass important milestone…………..

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Find Out If You Have Cancer in 10 Minutes

December 5th, 2018

Blood test to detect cancer within just 10 minutes developed by scientists

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Charge Master Rates & Magical Discounts

December 5th, 2018
A client on Reference Based Pricing experienced first hand the magic of Charge Master rates and magical discounts………………………….

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How to Bring the Big Health Insurers to Their Knees

December 4th, 2018

The American health care revolution is in full swing and growing………………….

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Missouri Chamber Health Plan Misses It’s Mark

December 4th, 2018

“When the data is hidden, you have no choice but to hope that the insurance company is managing your money appropriately.” – Adam Berkowitz

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Indemnity Insurance Plans Provide Best Coverage

December 4th, 2018

Plan liability is well defined and budgetable, patient liability is too…………….

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4 Reasons Reference Based Pricing Could Become The Norm

December 3rd, 2018

Reference based pricing isn’t new, nor is it unproven. The need to control still-growing health insurance costs will make more large employers sit up and take notice of the practice……………….

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The Wall Street Journal: Employers Change Tactics To Curb Health-Insurance Costs 

December 3rd, 2018


Company leaders are grappling with how to deal with the rising cost of health insurance in ways that get beyond the longtime strategy of simply passing on more of the burden to workers.

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Health Care Lobby VS Dale Folwell

December 2nd, 2018

“Lobbying? We’ve got 9 million taxpayers and 720,000 participants in this plan who understand that they aren’t consuming health care, it’s consuming them.” – Dale Folwell

Folwell’s plan is attracting national attention because of its far-reaching implications………………

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Montana Association of Counties Moves To Reference Based Pricing

December 1st, 2018

Why The Move to a Medicare Reference Based Pricing program?

The cost of medical services continue to rise at a rate far faster than inflation of other goods/services and faster than employees’ pay. Reference based pricing is the most effective tool we have to bend that cost curve. This change will mean less money going to health care expenses and more going into employees’ pockets. It also creates a system that is more fair, transparent, comparable and predictable than how hospitals charge us now.

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BCBS To Administer State’s Reference Based Pricing Plan

December 1st, 2018

If You Can’t Beat Them, Join Them…………………………BCBSNC embraces Reference Based Pricing in order to retain +700,000 employee lives in the great state of North Carolina……………..

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MY DOG HAS BETTER HEALTH INSURANCE THAN I DO!

November 30th, 2018

While chasing a squirrel in the woods, beloved pet dog tore the anterior cruciate ligament in her left knee. Turns out she had better insurance than her master………………………………

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State Health Plan Launches New Provider Reimbursement Effort

November 30th, 2018

       Dale Folwell

“For years, the plan has paid medical claims after the fact without knowing the contracted fee. It is unacceptable, unsustainable and indefensible. We aim to change that.”

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NC State Treasurer Displays Big Brass Cojones

November 29th, 2018

Now we know where Texas lost it’s cojones (Has Texas Lost It’s Cajones?)………..in North Carolina. Mr. Folwell, please bring them back! The upcoming Texas  biennial session needs them…..

“I’m calling for the United States Department of Justice and the North Carolina Department of Justice, on behalf of the State Health Plan, to recover the potentially hundreds of millions overcharged to consumers by hospital management from this illegal activity.” – Dale Folwell

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Replacing Employer Sponsor Health Insurance With Government Run Insurance

November 28th, 2018

This excellent White Paper examines some of the implications for health care financing and delivery were the U.S. government to supplant employers as the financer of medical care for most workers and their families…………………….

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Wait, Expensive Hospitals Aren’t The Best Choice?

November 28th, 2018

Dave Chase

When patients choose a hospital or other provider, they don’t really know what they’re getting………..The reality is that status quo health benefits are a horrible value proposition for employers and individuals……………

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How To Charge $1.6 Million For a New Drug And Get Away With It

November 27th, 2018

Call it a warning shot: last week an Indian patent court shocked the $600 billion global pharmaceutical business by ordering Bayer, the German health care giant, to allow a tiny Indian generic drug company to sell cheap copies of the blockbuster cancer drug Nexavar – even though everyone agrees that the drug is protected by a patent…………………..

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Is Medicare Part D Worth It? Dr. Dave Explores…………………….

November 27th, 2018

David Belk, M.D.

The question I’m addressing today is: How much help can you expect to get from your Part D plan when you use it to buy prescription drugs?

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Nevada Wades Into National Debate About Association Health Plans

November 27th, 2018

t’s history repeating itself.  Been there done that…………………..

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Why Self-Funding is A Better Way To Finance Health Care

November 25th, 2018

Milliman White Paper Shows How Self-funding Gives Employers More Control Over Medical Insurance Programs

MyHealthGuide Source: Jennifer Janvrin, CEBS, 11/2018, Milliman White Paper (full text)

Editor’s Note (Ernie Clevenger): This excellent White Paper by Milliman provides key values of self-funded and statistical tables to illustrate risk and risk management.

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Brazil Replaces Leaving Cuban Doctors

November 24th, 2018

Healthcare is Cuba’s most lucrative export. The “More Doctors” aid programme operates in 67 countries, and makes the island $11bn a year…………………..

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The Payer You Never Heard Of

November 23rd, 2018

You won’t see recognizable logos or insurance company names on their health insurance I.D. cards. You may wonder “what kind of insurance is this?”

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ER Doctors: 3 Priorities for Self Preservation…………

November 22nd, 2018

The three priorities in order of importance in practicing medicine: (1) Don’t get sued, (2) Make Money and (3) Take Care of Patients…………………………..

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Jenny & The Mexicats

November 22nd, 2018

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Cuero, Texas Home of The Turkey Trot

November 22nd, 2018

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Austin, Texas Sick Pay Leave Unconstitutional

November 21st, 2018

Judiciary says it’s unconstitutional, so legislators  have developed a cure of their own………….

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More Employers Are Leaving Fully Insured Plans………………

November 21st, 2018

“To gain control over the ever-increasing cost of employee health insurance, more and more employers are discontinuing their fully insured coverage and switching to self-funded models.”

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Health Care Ate America

November 21st, 2018

In the five decades after the passage of America’s two largest health care entitlements, that sector has become a maw, eating everything in its path. Health spending has reshaped the nation’s job market, its household finances, and its public budgeting…………………..

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Ending American Greed?

November 21st, 2018

“The greed of the prescription drug industry is literally killing Americans and it has got to stop…..”

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Texas School District Seeks To Exit TRS ActiveCare

November 20th, 2018

Once enrolled on the TRS ActiveCare health plan, school districts are forever prohibited from leaving. There are no exceptions permitted. Or are there?

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BenefitMall

November 18th, 2018

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Merloch Coins New Term For Reference Based Pricing

November 18th, 2018

Michael Meloch, President of TPAC Underwriters, comes up with a new term for Reference Based Pricing in a Phia Group podcast…………………………..

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Blues Plans Enjoy Record Profits

November 17th, 2018

Blue Cross Blue Shield plans have collected billions of dollars in profit in the first six months of this year………………………….Premiums have vastly outpaced the claims that the health insurers had to pay out to hospitals and doctors……………..

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Pfizer to Raise Prices on 41 Drugs in January

November 17th, 2018

   “Drug Costs Are Too Damn High”

As long as consumers purchase drugs with other people’s money big pharma knows consumer (market) blow back from pricing increases will be minimal……..

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Allied National Returns Unused Claim Dollars To Clients

November 16th, 2018

Allied National’s Funding Advantage contract returns unused claim fund dollars to employers who have favorable claims experience!

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I’m A Reformed Broker – Having Second Thoughts Is Not Possible…………

November 14th, 2018

Making $2 million on an 8,000 life Texas school district is really easy. I know because it’s been done, even as we speak…………………..

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AWP – Ain’t What You Pay

November 14th, 2018

INSIDE AWP: THE ARBITRARY PRICING BENCHMARK USED TO PAY FOR PRESCRIPTION DRUGS

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One Man’s Experience with Free Market Medical Care in the U.S.A.

November 14th, 2018

What’s ironic about this story, is this is exactly how we’d do it if our dog needed knee surgery…….

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Battle For Patient’s Wallet Moves To EHR

November 14th, 2018

“The only party not taken into consideration is the employer who is on the hook for the vast majority of the cost of drugs that will be sold through this channel……………….”

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Providers Push Back – N. Carolina Treasurer Pushes Back Harder

November 13th, 2018

“It doesn’t matter who the governor is, or who controls the legislature. It’s not political. It’s mathematical.”

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Jury Hits Aetna With $25 Million Judgement

November 12th, 2018

“Aetna pays its ‘medical directors’ bonuses for increasing the company’s profits by denying claims…….”

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Final Regs – Exemptions from Contraceptive Coverage Mandates

November 12th, 2018

Government continues to interfere in citizen’s sex lives……………………..

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Memorial Day 2018

November 11th, 2018

 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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How to Defend an ERISA Lawsuit

November 11th, 2018

Firestone deference – Many ERISA plans use plan document language stipulating the plan administrator has the authority to interpret plan terms and resolve any ambiguities. The United States Supreme Court has held that when a plan contains this language, courts must show deference to the administrators and review their decisions under an arbitrary and capricious standard…………….

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Healthcare Waste is Costing Billions…………

November 10th, 2018

………………and clients aren’t doing anything about it

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Sun Life Tops Market Expectations

November 9th, 2018

Business strategy is to focus on four pillars of growth: the Canadian home insurance and wealth market, US group benefits, global asset management, and distribution excellence in higher growth markets in Asia…………………………

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90+ Medications To Be Dropped by Insurance in 2019

November 9th, 2018

Drugs excluded includes brand-name drugs for which less expensive brand or generic alternatives are available in the market…………………………………..

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GR Data Insights: MSK – Quality matters………………

November 8th, 2018

Grand Rounds is focused on reducing high cost claimants and improving patient outcomes and we have tangible evidence to prove it……………………

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Here Comes The Judge

November 8th, 2018

 

 

He’ll give you time if you’re big or small
All in line for this court is neat
Peace brother, here comes the Judge 
Here comes the Judge…………………………………….

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Gridlock Sets In……………….

November 8th, 2018

With a Democratic House, a Republican Senate, and President Trump in the White House, get ready for two years of maneuvering but little progress on health care…………..

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State of Utah Fights High Drug Prices With Results

November 8th, 2018

The savings are anywhere between 38% to 75% well may save the state millions each year……..

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CMS Delays Dramatic Office-Visit Coding Changes Until 2021

November 6th, 2018

Proposed changes would have increased CPT 99213 by 30%……………..Primary Care Physicians lose out on pay raise. 

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