Is your third-party administrator holding out on you? Maybe you should check.
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.
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.
“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.“
“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.”
Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.
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.
“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
As health care costs escalate, Cost Plus / Reference Based Pricing plans gain traction within the employer community…………….
Hospital 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.
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.
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. ”
(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.
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.
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.
Some plan sponsors hire a third party administrator to manage costs. Others hire third party administrators to process claims.
“All we’re asking is for the federal government to do what they promised” – David Holmberg.
Need a low cost Windows solution for creating and managing Medicare and other RBRVS based fee schedules? Try RBRVS EZ-Fees…….
Blue Cross mobile enrollment office – when gas was 17 cents, and health insurance was affordable
In a deep dark recess of today’s Federal Register, large corporations just quietly received permission to “play doctor” with their employees.
“Those who say Cash Pay Plans are pie-in-the-sky dreams are mistaken. If man can fly then so can Cash Pay Plans.”
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.
Is HealthSmart TPA for sale? Word on the street says it is so.
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.
“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.
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.
Quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care.
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.
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.
New CEO takes charge………….Maxor to exit correctional pharmacy services?
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.
Why should you pay more to go to The Valley than the knuckle head sitting next to you?
“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.”
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
People travel to visit family and attend business meetings, so why not travel for medical care?
Walmart, Kmart, Safeway, and Kroger all charge $45 for the sildenafil, using the discount card, while Walgreens charges $450 and RiteAid $1,000…………
“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………… “