Litigation Update: Another Health Plan Lawsuit Alleging Mismanagement by Third Party Administrator

SOURCE: Haynes Boone – December 10, 2024

A recent complaint (“Complaint”) brought by Owens & Minor, Inc., in its capacity as plan sponsor of the Owens & Minor, Inc. Group Health Plan, a self-funded plan (the “Plan”), asserts that the Plan’s third party administrator, Anthem Blue Cross and Blue Shield (the “TPA”), breached its fiduciary duties to the Plan under ERISA. Specifically, the Complaint alleges that the TPA grossly overpaid certain medical claims on behalf of the plan sponsor and also pocketed pharmaceutical rebates that should have been paid to the Plan.

Musk Pitches Weight-loss Drugs to Lower Health Care Spending

Elon Musk, who is spearheading President-elect Donald Trump’s Department of Government Efficiency, is touting GLP-1 drugs to treat obesity.

Insurance for Organizations Who Make a Difference

Affinity Nonprofits

Aon Affinity Nonprofits is a brand name for the brokerage and program administration operations of Aon Affinity focused on the nonprofit sector. We specialize in developing, marketing, and underwriting customized insurance for nonprofit organizations.

Professional E&O Coverage

When you make a living off your expertise, you need comprehensive, cost-effective insurance to protect you financially from damages or legal costs that may arise.

Oscar Health CEO – “I Would Eliminate Employer Sponsored Health Insurance”

SOURCE: Finance / Yahoo.com

Oscar Health (OSCR) CEO Mark Bertolini sits down with Seana Smith, Madison Mills, and Anjalee Khemlani on Yahoo Finance’s Catalysts, addressing some of the various frustrations Americans have with the state of the US healthcare system.

Rx Gross To Net

By Christopher V. on Linkedin

What does “Gross to Net” really mean?

Yesterday I posted about the Assistant Secretary for Planning and Evaluation – HHS report on the first two years of RxDC data.

Gross to net in plain terms refers to the difference between a drug’s list price (the sticker price set by the manufacturer) and the actual amount that is paid after discounts, rebates, and other price concessions are applied.

Phia Group Beats IDR Statistics

By Adam Russo

A recent Health Affairs study underscores the challenges health plans face in the Independent Dispute Resolution (IDR) process, with a win rate of just 13.5%. In stark contrast, Phia clients benefit from a remarkable 53% success rate in IDR outcomes, including wins and dismissals.

How To Avoid Making Uncle Sam Your Richest Beneficiary

By Ross Friend -November 2, 2024

I have had several clients pass away in the last 12 months and all with different “types” of beneficiaries, e.g. spouse, family trust, children, siblings, with varying degrees of planning efficiencies in distributing the client’s wealth. Poor planning or failure to update one’s intentions can and may lead to an unexpected outcome, i.e. ask the IRS. There is never a bad time to ensure the client’s assets are reviewed for the most efficient tax transfer and aligned with their objectives. The SECURE Act changed the retirement and estate-planning landscape and you need to be aware of the tax efficiencies available whether you are a surviving spouse or not.

Diagnosing Vital Signs

“Please step on the scales” says the harried nurse assistant followed by “Have a seat and let’s take your blood pressure and temperature.”

Meakin Metabolic Care

MMC offers comprehensive and evidence-based metabolic care to all patients, with a specialized metabolic program tailored for cancer patients to complement conventional treatment.

MedSave Health Plan

“The first $8,000 is on me. The next $8000 is on you. Everything above that is back on me” said the employer. “Whatever you don’t spend of the first $8,000 is yours to keep.”

Solving Health Care One Client At A Time

The Tyler Rose (on the left) and her partner have been described as “A force of nature.” If you’re an employer and don’t know them you should. If you’re a competitor and don’t know them you should fear them.

Gallagher to Acquire AssuredPartners for $13.45 Billion

9th December 2024

By Kassandra Jimenez-Sanchez

Arthur J. Gallagher & Co. today announced it has signed a definitive agreement to acquire AssuredPartners, a US insurance broker with client capabilities across commercial property/casualty, specialty, employee benefits and personal lines, for a gross consideration of $13.45 billion from GTCR.

You Remind Me Of Your Grandmother When You Smile!

Bad Handwriting Can Kill You

Health Insurance Is Cool Because…….

GLP-1 Weight Management For $250/Month

Blue Light Special – Order your Will Power Drug for only $250 per month, or $3,000 per year online without the hassle of spending hours away from work sitting in a germ infested waiting room of moaning, coughing, sneezing walking dead people.

ACA Sales Way Down This Year

By Sam Melamed

ACA sales continue to be way down this year compared to last and the numbers are fun to dig into for a data nerd like me. Some interesting angles emerge when analyzing the data that tell a pretty powerful broker story. The dataset compares FFM ACA sales and State based exchange enrollments this year vs last year and the data comes directly from CMS.

Elon Musk Questions U.S. Healthcare Costs Amid CEO Murder Investigation

Billionaire entrepreneur Elon Musk has sparked fresh debate over the value of the U.S. healthcare system, calling for Americans to get “their money’s worth” after data revealed skyrocketing administrative costs.

Marpai 10k Report

The following excerpts are from Marpai’s SEC Q10 Report ending September 2024

“Based on our current financial condition, our Board of Directors, supported by our management team, is considering exploring strategic alternatives focused on maximizing shareholder value.”

4 Keys To Patient Navigation

By Eric Bricker

Learn from the experience of one of the original patient navigation companies: Compass Professional Health Services. I founded Compass with two other co-founders and together we grew the company to 1.8 million members across 2,000 employer clients over 11 years.

Anthem BCBS Backs Down On Plan To Limit Anesthesia Coverage

By Susan Rupe

Anthem Blue Cross Blue Shield is backing down from a plan that would have set limits on the amount of time it would pay for anesthesia in certain surgeries.

Deadline for Submitting Gag Clause Attestation Is Dec. 31, 2024

By Bolton • December 5th, 2024 SOURCE: https://www.boltonusa.com/deadline-for-submitting-gag-clause-attestation-is-dec-31-2024/

Effective in 2020, the Consolidated Appropriations Act, 2021 (CAA) prohibits health plans and health insurance issuers from entering into contracts with health care providers, third-party administrators (TPAs) or other service providers that contain gag clauses (i.e., clauses restricting the plan or issuer from providing, accessing or sharing certain information about provider price and quality and de-identified claims).

Need Accident Insurance?

Ivan Unger and Gladys Roy were the two responsible for this jaw-dropping stunt on the wings of a biplane in 1925. The two were successful in playing what has to have been the most dangerous game of tennis ever played and, as biplanes are a thing of the past, a stunt like this is unlikely ever to be pulled off again.

The Kennedy Wellness Program or Will Power Medication?

Few have the willpower required for diet discipline and look to Will Power medication for a cure.

Craig Gottwals Opines

Alleged Carrier Fraud, Direct Primary Care and Which Companies Best Reference-Base Price

“Bundling self-funded plans with a carrier as your TPA, network, and PBM? A recipe for disaster. If you’re large enough to self-fund, don’t bundle. Period.

Tx. Gov’t Code: Request For Qualifications

Texas Procurement and Contract Management Guide :

“A Request for Qualifications (RFQ) is generally used for professional services wherein the respondents are evaluated based solely on their qualifications and skills.”

Health Insurance For Animals

UnitedHealthcare CEO Brian Thompson Murdered

The NYPD confirmed the shooting, which cut UnitedHealth’s investor conference short on Wednesday morning, though not Thompson’s identity. Thompson, 50, had been with UnitedHealth since 2004.

How Much Do Health Insurance Brokers Make?

I have been working as a fee-based health insurance consultant for more than 25 years. The other day I was visiting with a wholesale broker and asked him how much do brokers make these days. He works with all the big houses and a whole lot of mom and pops.

Sanford Health Is A Federal Outlaw

By Bill Hennessey

I called to get the cash price for an urgent care visit. And they pulled the ole’ Abbott and Costello “who’s on first base? And yes, these ladies I spoke with were rude and condescending to me.

Plan Sponsors Still Covering Humira Are Overpaying

By Adam Berkowitz

Humira (WAC): $6,922

After Rebate: $4,922

Amjevita: $1,385

Yusimry: $995

Abrilada: $1,038

Hadlima: $1,038

adalimumab-aaty: $275

Liberty Mutual Offer For You: You Could Save $700 + 12-month rate Guarantee

View your online quote here.

No Thanks. One Beer is Enough!

“I used to drink 99 beers but now only one does me just fine!”

Dizzy after one drink? Social drinkers on obesity drugs lose the taste for alcohoL Many social drinkers who take obesity medications, such as Wegovy or Mounjaro, say they don’t enjoy alcohol as much.

pharmpix – A Virtual Full Service PBM

SOURCE: PHARMPIX

A “virtual” full service PBM with an adaptable business model for different pharmacy delivery solutions. Establish a deeper connection with your beneficiaries and providers and save along the way.

Are You NADAC Ready? Staying Ahead of the Drug Pricing Landscape

NADAC pricing is gaining traction in the PBM industry due to its role in pricing transparency, reimbursement negotiations, cost management, formulary management, regulatory compliance, and alignment with industry trends. It offers a standardized benchmark for drug pricing, promoting fairness and transparency in the healthcare system.

Life Insurance For Diabetics

Life insurance for people with diabetes, cancer, heart conditions and other deadly diseases?

FTC Report on PBM Consolidation

FTC Releases Interim Staff Report on Prescription Drug Middlemen

Report details how prescription drug middleman profit at the expense of patients by inflating drug costs and squeezing Main Street pharmacies…….details how increasing vertical integration and concentration has enabled the six largest PBMs to manage nearly 95 percent of all prescriptions filled in the United States.

Class Action Lawsuit Challenges Noncoverage of Obesity Drugs

“This case is about disability discrimination in the provision of healthcare coverage. Specifically, this case is about a health insurance company’s categorical exclusion of prescription medication for the treatment of obesity and the resultant discrimination against people with the disability of obesity.”

Why Would I Want To Work For Less?

“Yes, that’s right! The average rate of pay for risk managers is $106,000 so why would I work for less? My work product is not below average, it’s well above it.”

Harris Rosen

Harris was a business man who practiced manage care to a degree few others can imagine. He reminds us of Ruben Edelstein.

Official Admits To COVID Fairy Tale

“I probably shouldn’t be saying this out loud” Chief Confesses COVID Health Initiatives Were “COMPLETELY MADE UP”

Government Proposes Sending Billions In Drug Money To Denmark

Unreliable inside sources tell us executives at Novo Nordisk, Europe’s largest company and producer of ozempic, are excited beyond their wildest dreams after learning government printing presses in Washington may be sending plane loads of cash laden pallets their way.

“This will help offset the loss of the North Carolina State health plan and the University of Texas health plan“ said a jubilant C-suite executive.

HSA Company Accused Of Defrauding Consumers, Confiscating Funds

An HSA card

A Houston-based health services account provider is accused of stealing clients funds in a class action lawsuit filed in a Houston federal court.

Sit Down, Shut Up, and Accept It!

Hannah Tells Plan Sponsor How The Cow Ate The Cabbage

By Craig Gottwals

“Substitute ‘Anthem’ with any major insurer, and the story remains the same…. Anthem told Owens & Minor, a self-funded employer, that they wouldn’t release essential claims data because it might reveal ‘confidential’ provider arrangements …

Boon-Chapman Partners With Zakipoint Health

Zakipoint Health & Boon-Chapman Announce Strategic Partnership to Transform Healthcare Navigation & Member Engagement

Is COBRA Relevant Anymore?

Is COBRA relevant anymore? Not when you can get your own ACA mandated policy with comparable coverage for less cost.

How To Spot A Diabetic

Visual clues on how to spot a diabetic across the room.

ACA Re

Lucky Mary Loves Her Black Market ICHRA

Transferring high risk plan members by way of an insurance policy is nothing new. Self-funded health plans routinely purchase stop loss insurance for that purpose. Others have found another method made possible by the Affordable Care Act (ACA). We call it ACA Re, the best tax supported stop loss policy scheme ever designed by Congress.

Physicians & Surgeons Disability Plan

Physicians & Surgeons Disability Insurance Plan is designed to provide men and women working in the medical field with proper levels of income protection.

Ladder Life Insurance

Life insurance so good they will want you dead………….

Feeding Brokers At The Expense of Starving Ones

By Bill Rusteberg

In 1982, after nine years of corporate servitude, I left the inner sanctums of a large health insurance company and the comfort of receiving a corporate paycheck every two weeks whether I earned it or not.

Will the Affordable Care Act Survive A Trump Presidency?

President-elect Donald Trump has repeatedly vowed to repeal the Affordable Care Act (ACA), which ensures that 45 million Americans have access to health insurance. Will he finally deliver on his promises?

Non-Profit Hospital Pays CEO $5.6 Million Bonus

Children’s Hospital of Philadelphia delivered a record $7.7 million pay package to CEOMadeline Bell in 2021, as the coronavirus pandemic wreaked havoc in the health care industry, with deaths mounting and labor shortages putting nurses and other hospital staff under duress.

Carriers Compete For Broker Loyalty

Years ago when I was a commission driven insurance whore a TPA dropped by my office. “Bill, how many self-funded lives do you have on how many groups?” he asked. “Move 2,000 lives to us and I will not only pay you the same commissions you’re getting now but I will personally deliver a $250,000 check as our way of saying THANK YOU for the business!!”

Such is the world of health insurance brokerage…………………..

RFK Jr. Planning Major Changes To Medicare?

According to The Washington Post, Kennedy wants to overhaul Medicare billing codes.

Rx Reference Based Pricing

The high cost of prescription drugs is bankrupting health plans leaving plan sponsors little choice but to take action. The following describes two methods that will reduce drug spend by as much as 50%.

Here’s Proof PPO “A” Has The Best Discounts!

“The carriers are very good at playing this game and my belief is that most consultants don’t get it or pretend not to get it, thus doing a great dis-service to their client.” – PHO Sales Representative

Standing for Health Plan Excess Fee Cases – Do the J&J and Wells Fargo Health Plan Excess Fee Cases Meet the MetLife Decision’s High Bar for ERISA Defined-Benefit Plan Standing?

“They (J&J) want the right to file fiduciary-breach claims with no rules. It is a bold and brazen position. Surely Congress should amend the ERISA statute to protect against this type of litigation abuse.”

Chargemaster Duns Dead Person $181,102.03

Chargemaster, who no one ever pays, chases dead person for money. Takes grave robbery to a new level.

Will the hospital collect full chargemaster rates from the dead person? If not, will they write off the entire amount as charity care when their cost was a fraction of that?

CHARGE MASTER: Medical Bills Paradox

“We have to charge everybody more because we give away millions upon millions of free charity care!” says the hospital administrator. “Just look at what we charged off last year, over $1 billion! But we don’t mind because our policies are compassion based.“

“But almost no one ever pays chargemaster rates!” says the attorney. “Isn’t that true?“

“Objection!” screams the opposing side. “The plaintiff’s attorney is trying to sway the jury!’

Why Americans Don’t Fight Back

By Dutch Rojas

Despite rising premiums and dwindling options, most Americans remain passive.

The Physician in the Machine

Machine 1 to patient: “I’m referring you to Machine 2 for surgery. Here’s your password…………”

Big Pharma Launches Stop Kennedy Effort

This is going to be interesting. Vested interests are going to have to show their hand. Who will win?

8 Questions That Destroyed A PBM Relationship

A group with an annual pharmacy spend of $3.5 million decided to build their own formulary and asked their PBM if they could administer it. “Yes, of course” they said, “But our fees will go up.”

Patternicity in Health Care

“Sometimes it takes a prick to solve health care”

Our brain is a belief engine fueled by outside stimuli, recorded, sorted and placed in filing cabinets in our cranial warehouse to be retrieved at will when needed.

The Health Marketplace for All Act of 2024

The Health Marketplace for All Act of 2024 would allow any membership organization — which includes wholesale clubs (such as Costco), credit unions, and churches, among others — to offer an ERISA health plan to its members “across state lines—regardless of an employment relationship.”

Thatch Partners With Quickbooks To Bring ICHRA To Millions Of Small Businesses

This is more evidence of the explosive growth of ICHRA, compelling evidence tech-based vendors lead the future of health care financing and market distribution.

What is the Best Health Insurance Plan?

“For most people it is one that costs less. Group plans impose the costs on all because some minority want a richer plan or some bigger network. This is just another reason to move to an ICHRA.”

Emily

The following is based on a true story with an ending yet to occur. Suspense builds as the story unfolds towards its inevitable ending that’s sure to come. It is a struggle between right and wrong, greed and compassion, power and the powerless, David vs Goliath.

Healthcare Rebel Alliance: Q&A with Richard Hirsch, BillingNav

” I hate injustice and the abuse of power, and it angered me to see how hospitals and certain medical practitioners profit at the expense of people who do not have the ability to protect themselves from such abuse.”

The Best Work Comes Out of Great Relationships

By Bill Rusteberg

As a self employed insurance agent I’ve worked with hundreds of clients over the past 50 years, the result of calling on thousands more in prospecting efforts to gain more business. I’ve met all types of personalities, developing a skill few have. Understanding motivation, goals and interests is secondary to understanding moral and ethical values of those you strive to do business with.

Marpai Expected To Reduce Expenses By +25%

“We continue to identify opportunities for further efficiency gains. A major project currently underway is expected to reduce TPA expenses by over 25% in Q1 2025……Marpai is gaining significant market traction and has a robust sales pipeline extending beyond Q1 2025.”

Never Under Estimate The Little Guy

Imagine Ruiz is an independent insurance consultant and Josua is a national well branded consulting firm with offices throughout the Fruited Plains. Which one do you think will get the business responding to a RFQ for consulting services?

Blue Cross Employee Wins $12.6 Million For Saying “NO!”

A woman fired by Blue Cross Blue Shield of Michigan for refusing to take a COVID-19 vaccination has been awarded more than $12 million in damages.