Bob Sheehy, the former CEO of CEO of United Healthcare UNH 0.76% , is back with a new startup called Bright Health.
This might be the first time in US healthcare history that a federal ERISA court grants a permanent injunction against a violative insurance company or health plan.
Is 125% of Medicare a reasonable reimbursement rate? Patrick Rooney thought so back in the 1980’s. Many believe it still is.
Several of the BUCA’s pay less than that for out-of-network provider pricing. We have seen some of the BUCA’s pay out-of-network hospitals 105-110% of Medicare.
Our book of business primarily employs reference based pricing strategies paying hospital / facilities 120% of Medicare since 2007. – Bill Rusteberg
An official blasted the Office for Civil Rights for going too easy on the covered entities……..Next round of audits to be tougher and could lead to legal action…….
Your Billing Is Too Damn High!
According to the Houston Chronicle, at least a dozen lawsuits have been filed in the city in recent years over what insurers claim is an incorrect practice: private hospitals offering patients lower rates that compete with “in-network” facilities by billing the insurance company more.
DoctorGlobe launches first online hospital-shopping platform to help self-funded employers discover better care for less featuring an algorithm that ranks 120+ surgery procedures across 2,800+ hospitals nationwide by quality, distance and price.
“PPO networks are a quaint artifact of pricing failure……….if you study the numbers, it is impossible to not come to the conclusion that healthcare is the single greatest threat to America. As Klein pointed out, inflated pricing is public enemy #1.”
Hospitals, Physicians, Big Pharma and Insurance Companies have been dictating pricing and making the rules continuously for decades………..The rigged game of health care is similar to the Kobayashi Maru….
“All (insurance) companies offer bonuses” to consultants. “It’s a way to sell the product and saves them from hiring 20,000 agents,” – Joe Grady
The Justice Department is preparing lawsuits to block two giant health insurance deals, according to a person briefed on the matter, continuing a spate of antitrust actions in a whirlwind year for mergers and acquisitions.
Plan sponsors want to know which PPO network has the best and lowest costs. They hire consultants to find out.
This settlement also could reflect an ongoing “raising of the bar” by HHS where HIPAA compliance is involved……………University did everything right except relationship with cloud vendor………
Many Texas employers have been using reference based pricing strategies since 2007. These early adopters have enjoyed great success in containing medical costs. All have succeeded in beating medical trend, maintaining static costs while improving benefits.
Markets sometimes take time to adapt, as the status quo is always in the best interests of vested interests, including insurance brokers, carriers, TPA’s, hospitals and managed care organizations. Now we are seeing reference based pricing strategies gaining rapid market growth. For example the state of Montana adopted a reference based pricing for the state’s employees just this month. – Bill Rusteberg
There has been a proliferation of ADA lawsuits alleging that websites are not accessible to the blind or deaf. …….Target pays $6 million punishment fine to government…………..
I wanted to update everyone on what I thought was a rather curious comment I found posted on the blog I wrote two weeks ago about United Health Group. You might remember that, in the blog, I questioned whether United Health had really lost money on the ACA exchanges last year. See – Belk Digs Into UHC Finances – Questions Motive To Leave ACA Exchanges
Politician-Attorney Fighting For Plaintiff’s Lawyers
It’s all about protecting one’s profession and not at all about protecting consumers. It’s all about government taking care of people who are too stupid to take care of themselves. It’s all about government interference in a free market economy where sellers and buyers choose who to do business with.
“This is as clear as I can make it, if you work with one of the big healthcare carrier (ASO) companies there is no transparency and there never will be. “ – Mike Dendy
“Insurance companies continue to look out for their medical provider partners. Secretive managed care contracts between these conspirators continues to assure annual increases in reimbursement rates, year after year. “
“It’s true that 90% of health insurance rates go to pay medical caregivers. The more providers charge for their services the higher the rates need to be. The only method to reduce health insurance costs is to reduce fees paid to medical caregivers as the State of Montana has done this year under the state employee health plan. It’s that simple” Homer T. Farnsworth, M.D.
“According to industry experts, more and more CEO’s, CFO’s and Plan Administrators are exposed to tremendous liabilities due to poorly managed or “Head in the Sand” monitoring practices. As we have written about and predicted, this is evidence of the growing trend of self-insured health plans being exposed to tremendous liability by TPA’s.”
“These cases also illustrate an ironic twist, in many cases, the ASO agreements prohibit the plan from auditing the claims that the TPA’s are paying on behalf of the self-insured plan, which on its face, seems to be a remarkably absurd clause that any plan sponsor would agree to sign.”
A billion dollar gift and no thank you note is something mother would have never approved.
KGA has identified providers that offer transparent, greatly-reduced, all-inclusive cash prices. These providers allow KGA to utilize this pricing because the claims are paid quickly and at 100%. Plan participants utilizing a Kempton Premier Provider for a covered medical procedure benefit by incurring no out-of-pocket costs and the plan receives substantial savings. It’s a “win-win” for all parties involved.
Montana adopts reference based pricing model for state employees. Will other states follow?
“The last category of independent insurance consultants are those that are never comfortable outside their insulated environment. They like the warm and fuzzy feeling of staying at home in a loving environment with Mommy.”
Critics of Obamacare warned in 2009 and 2010 that the so-called “Affordable Care Act” was merely a “Trojan Horse” that would eventually to a complete government takeover of health care. For that, conservatives were mocked and demonized.
“As more employer groups have adopted this strategy, hospital and provider groups have begun to take notice and push back. Therefore, the future of these plans is still uncertain” – Scott Aston
Editor’s Note: The author is mistaken. The future of Reference Based Pricing plans is not at all uncertain. PPO’s are going away, replaced with common sense and prudent business practices. Plan Sponsors are on to the PPO game and don’t like what they see. They are mad as hell and not taking it anymore.
Andy, if you want to fix primary care you must do some field research. Come spend one day, or even a week at my office or another small primary care physicians’ office. You need to see what we do on a daily basis……………
A range of legal decisions and fact sheets released by government organizations in recent months are expected to have an impact on employee benefit plans. In the wake of these cases and related guidance, advisers and employers should review their policies on topics such as cash-in-lieu of benefits, pregnancy discrimination, health questionnaires and arbitration agreements.
A scheme to withhold, embezzle, and convert ERISA plan assets through a pattern of fraudulent benefits transactions and prohibited self-dealing……..Practices that may be endemic to the industry as a whole?
By Molly Mulebriar
When a hospital refuses to accept a patient because their health insurance plan limits allowed charges to 120% of Medicare reimbursement rates, and instead offers to discount their charges by 15%, one wonders how much more will the patient be asked to pay.
Of note is the hospital routinely accepts 100% of Medicare from Medicare patients.
Since hospitals never disclose their charge master rates, agreeing to pay in advance for medical services on the basis of a 15% discount off an unknown number makes no sense at all. We don’t agree to purchase any other goods or services on that basis so why would we do so for health care?
Fortunately in Texas, there is a law that requires hospitals to provide a cost estimate in advance of services rendered, unless the charges are for immediate emergency care.
According to the Texas Insurance Department website “Texas law gives patients the right to request estimates of charges. Doctors and other providers and health plans have 10 days to give you the estimates.”
Mayor wants hospitals to reveal the actual cost of providing care so the city can determine if prices are too high.
By Bill Rusteberg
“Balance billing only occurs when purchasing goods or services without asking the price.”
“United Health Care announced last fall that they would be pulling out of the ACA exchanges because the Obamacare policies were costing them too much money. I thought that was a curious announcement since, according to their financial statements from last year, they appeared to be doing quite well.”
“I’m really starting to wonder if I’m the only person who ever checks financial statements” – David Belk, M.D.
Continental Benefits has brought some of the brightest and most entrepreneurial minds in healthcare together with a focus on not just stepping outside of the box, but tearing it down and building something entirely different……..
“Jeff Bernhard is one of the rare senior executives who has left one of the big national health insurance carriers to truly solve the issues the large carriers mainly pay lip service to. He’s running Continental Benefits that is described as a “super TPA” as they go beyond what traditional third-party administrators do and apply some of the proven Health Rosetta approaches.(Super TPA – The Purple Cow of Health Care) They are growing rapidly and are one to watch.” – Dave Chase, Forbes Contributor
Government mandated risk sharing among insurers to cover pre-existing condition losses has merit. But is it fair?
The scheme continues. Shared savings off imaginary numbers through PPO discounts negotiated in secret and subject to gag orders, effectively screws consumers by driving costs up. There have been numerous lawsuits in recent years against Cigna, Blue Cross, Aetna and others with pleadings summarizing identical complaints.
Plan sponsors are at extreme risk as evidenced by the following article by Mark Flores. As plan fiduciaries they are liable for potential lawsuits. Hungary attorneys and outraged consumer groups are beginning to take note – Molly Mulebriar, Waring, Texas
Skilled at lying to attract and retain business, playing on the ignorance of unsuspecting prey, this ingenious fabricator of fiction is considered a perfect candidate for the Bridge Inn contest. Smart money has 5 to 1 odds on a Texas win this year.
“It’s such a complicated web of intermediaries that stand between consumers and the prices they pay,” said Erin Fuse Brown, an assistant professor of law at Georgia State University College of Law. “As a result, no one knows if they’re getting ripped off.”
Health insurance indemnifies insureds against loss. It is the insured’s responsibility to settle outstanding medical bills, not the insurance company. However, the temptation to cash insurance company checks and buy fajitas and beer can be as powerful as winning the Texas lottery and buying more fajitas and beer.
Texas Free Market Surgery is a partnership between the best surgeons and innovative business partners with a vision to supplant a broken healthcare system with a new innovative model that delivers the best care at affordable prices for patients and families.
Revamping traditional Medicare’s benefit design and restricting “first-dollar” supplemental coverage could reduce federal spending…………..Medicare Supplemental Coverage in danger of extinction?
Is your third-party administrator holding out on you? Maybe you should check.
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.
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
These results are excerpted from the Blue Cross Blue Shield edition of the 2016 Sherlock Expense Evaluation Report.
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.
Some Texas political subdivisions have reduced costs and improved benefits. Others have experienced the opposite.
Texas is seeking competitive proposals for TPA services for the state’s employee health & welfare plan.
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.”
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.
The operation is designed to combat glaucoma, which can lead to permanent loss of sight.
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.
“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.”
Insurance 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?
“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.”
Employers are facing significant risks from data breach but few are prepared for the consequences……
A 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.
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………….
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
The 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.
“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.”
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.”
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.
Obamacare 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.
“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…………”
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……….
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.
Flanders, 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.
“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.”
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.”
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………………..
Jobs 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.