“Preferred Provider Organizations (PPOs) perpetuate overpayments…………. average payments to hospitals of 250% of Medicare or more is horrendous, in many markets payment levels are twice that level and employers have no idea.”
Doctor sentenced to 30 years to life in prison for the murders of three of her patients who fatally overdosed…………..
“Market forces clearly have no effect whatsoever on the prices of brand name medications…………..”
Do Your Assignment of Benefits Clauses Need a Check-up? Recent Southern District of Florida Decision Highlights the Importance of Carefully-Drafted Provider Assignment Clauses
Cash pay reimbursement strategies should be an integral part of any self-funded employee health insurance plan………..
“THE PRICE IS TOO DAMN HIGH!”
Trump’s proposal is just the latest indicator of the increasing bipartisan support for government action on drug pricing……
Four ambulatory surgery centers alleged that two hospitals agreed to use their combined market power to compel physicians in the market not to refer patients to their competition and enlisted support from several carriers active in the health insurance market………
Money that would have otherwise gone into investments or infrastructure development is now being diverted to employee healthcare benefits, and that has implications for the long term viability of every organization. (See Most Companies Shirk Fiduciary Duties When It Comes To Health Care)
MPIRICA offers free access to Provider Quality Scores for employers and plan participants……………..
Prescription drug shortages are the new normal in American medicine. But the rationing that results has been largely hidden from patients and the public.
An excerpt from the preceding post on this blog (Florida Business Coalition Set to Revolutionize Health Benefits Purchasing) says it all. Some plan sponsors are better at managing fiduciary duties than others. They take these duties seriously while others simply ignore common sense, fail to understand health care financing and rely on vested interests memorialized through contracts of adhesion.
Perhaps the finger of blame for the high cost of health care should be directed at the payer, not the medical provider community – RiskManagers.us
Orlando-based Rosen Hotels have shown how straightforward it is to slay the healthcare cost beast. They spend 50% less on health benefits than a typical employer while providing outstanding benefits
Libbi Stovall couldn’t believe it last month when she looked at the fine print in her company’s 2016 health plan, which supposedly meets the strictest standard for employer obligations under federal rules.
Immediately reduce health benefits costs by $50K, possibly $250K or more……….
Litigation involving out-of-network providers, meaning providers who do not have a negotiated rate agreement with the respective payer, continues to be rampant. Certain issues arise frequently in these lawsuits over whether the payers had properly paid claims.
This article discusses several published decisions from 2015 that illustrate how courts across the country are handling some of these common issues.
ClearHealth delivers comprehensive Medicare-based pricing programs that are fully configurable to allow your organization to achieve maximum savings while using a cost containment strategy tailored to meet your strategic goals.
Part of a continuing series………..(See previous two posts)
“Reasonable charges for inpatient and outpatient facilities generally equal twice a facility’s cost as reported by the facility to CMS….” Read the rest of this entry »
By Molly Mulebriar
In our continuing efforts to expose insurance industry secrets that drive up health care costs, we find more evidence of third party skimming through managed care contracts.
PPO agreement requires self-funded plan to pay certain claims that otherwise would be denied……………………..
The current single payer system in Canada presented a solution in a time when farmers, who had little or no money for healthcare, represented the major demographic in the country and a cooperative type model was therefore attractive.
But times have changed……….…………………
Actuaries ponder philosophical mutterings under the basis of implied thought influenced through critical thinking……………..
Does your TPA, broker or consultant provide actuarial support as part of their service offering? An actuarial analysis should be performed annually. A small cost factor in overall plan spend, actuaries provide essential services important to fulfilling fiduciary duties.
Dale chose not to take his work-sponsored health assessment and biometric screening. His company responded by pulling his insurance coverage.
A growing number of primary care doctors, spurred by the federal health law and frustrations with insurance requirements, are bringing a service that generally has been considered “health care for billionaires” to middle-income, Medicaid and Medicare populations.
By Drew Altman
Medical bills for out-of-network providers can surprise consumers with thousands of dollars in costs they didn’t plan for and sometimes cannot afford.
Stress Reduction Kit For Frustrated Plan Sponsors
Drugmakers didn’t let up on price increases with the start of a new year, demonstrating the industry’s pricing power in the face of mounting criticisms of prescription costs in the U.S.
“The District invited one thousand four hundred sixty-two (1462) vendors to submit a proposal and six (6) vendors responded.”
“Amazing stuff – who would have guessed there were that many licensed insurance consultants in the state” – Molly Mulebriar
“Reference Based Pricing represents the last frontier in innovation to control health care costs in a tightly regulated and controlled market”– Bill Rusteberg
This is another of many recent examples of a third party intermediary’s alleged embezzlement of plan assets deceptively concealed through fake PPO discounts.
A BCBS survey was conducted and found that 83 percent of its self-insured clients were completely unaware of the hidden fees…………
An idea with bi-partisan support?
If the federal government would rent their Medicare network and charge what the private market charges for PPO access, the government would rake in millions, if not billions of dollars in access fees. This would generate enough money to buy health insurance for those that don’t need it.
Due to pricing fraud, many payers, including government payers, are no longer using AWP for pricing, and are switching to other more transparent pricing benchmarks…….AWP is subject to fradulent manipulation by manufacturers or even wholesalers. As such, the AWP, while used throughout the industry, is a controversial pricing benchmark….
Munninghoff said his accounting firm’s experience with TrueCost influenced his decision to invest in Custom Design Benefits.
An exclusive new product called TrueCost, a reference-based pricing solution for firms with as few as 50 employees was developed by Custom Design Benefits in 2012, TrueCost eliminates deductibles and co-insurance and reimburses all medical providers based on Medicare plus a bonus.
“Reduce your costs by moving employees onto free health insurance with Medicaid Migration”……….
Are private, free enterprise employers who traditionally oppose government interference in business actively encouraging growth of a massive entitlement program many are philosophically opposed?
Companies shift insurance costs to the government….……….
Employers have not historically played a significant role in helping workers enroll in Medicaid……………..until now
Swiss Re Corporate Solutions has signed an agreement with Independence Holding Company (NYSE: IHC) to acquire IHC Risk Solutions, LLC and its direct employer stop loss (ESL) business, for an aggregate of USD 152,500,000 in cash.
“This model will incentivize providing patients with the right care the first time and finding better ways to help them recover successfully. It will reward providers and doctors for helping patients get and stay healthy.”
Health insurers who administer self-funded plans for employers have no incentive to keep costs down, rather the incentive is to drive costs up to earn higher administration fees as well as fees earned off PPO spread pricing – Homer G. Farnsworth, M.D.
What Do Three Men, A Hotel & A Third Party Intermediary Have In Common With Health Care Financing?
In this illustration, you will learn how RiskManagers.us skillfully portrays an illusion to reduce inflated billed charges by almost 17% , saving each of the three men 10% while enriching a third party intermediary by approximately 7% of billed charges with an additional + 3% vanishing inexplicably into thin air.
Understanding this riddle will clearly show how opaque and illusionary health care financing can be…………………..
By Molly Mulebriar
Recently I was asked to assist a speaker in preparing for a talk to be given to an audience of hospital administrators at their annual convention. The topic was “Why You Should Be Prepared For Direct Contracting with Local Employers.” So I wrote the following advice:
Could this be a gifting of public funds with no basis upon which to determine best value?
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.
The plan conducted a claims audit in 2004 and found that Great-West had paid almost $1 million in out-of-network claims in full as billed, rather than as a percentage of the usual, customary and reasonable charge.
Penske Truck Leasing is working with Aetna and Teladoc to offer virtual services to its 18,000 employees, 20 percent of whom have taken advantage, according to the company’s vice president of benefits and compensation, Joe O’Neill.
“There is no justification for these outrageous rates,” says Prof. Anderson, “but no one tells hospitals they can’t charge them. For the most part, there is no regulation of hospital rates and there are no market forces that force hospitals to lower their rates.”
Editor’s Note: “Market forces” and “Regulation of Hospital Rates” are not synonymous.
Free Health Care For All
To finance the project, Colorado employers would pay nearly 7 percent in a payroll tax. Employees would pay 3 percent or more of their gross pay toward the health plan. The self-employed would need to pony up 10 percent of their annual net income…..
Greetings, I hope everyone is enjoying this holiday season.
About three weeks ago I was interviewed for a show called Mind the Business where I discussed three stories that had been in the news recently about fraud and conflicts of interest in healthcare.
If hospitals defraud Medicare, could they also defraud private pay health plans too? Most plan sponsors don’t audit their health care claims either because they never have “so why start now?”, or they are prohibited from doing so through contracts of adhesion i.e, managed care contracts.
We use our industry expertise to help you develop and execute strategic plans that evolve your business.
The most shared article on this blog for 2015 – Lawsuit Exposes Insurance Industry’s Best Kept Secret
RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.
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You may know a hospital by its general reputation, but is it really the best place to go for the specific type of surgery you need? And is it true you “get what you pay for” in health care? Do higher prices mean higher quality?
Risk Manager: “Excuse me Mr. Fox, there are some hens missing”. “Can you check the security cameras to see what happened?”
BCBS: “Sorry, the images on those cameras are proprietary”. “But here is a letter stating we didn’t steal any hens.”
Martin Shkreli, the boyish drug company entrepreneur, who rocketed to infamy by jacking up the price of a life-saving pill from $13.50 to $750, was arrested by federal agents at his Manhattan home early Thursday morning on securities fraud related to a firm he founded.
Shkreli’s extraordinary history—and current hold on the public imagination—makes the case more noteworthy than most involving securities fraud. The son of immigrants from Albania and Croatia who worked as janitors and raised him deep in working-class Brooklyn, Shkreli both epitomizes the American dream and sullies it.
In the early hours of December 16, 2015, Congressional negotiators reached………….
New study claims that as much as 80 percent of employers face prescription drug abuse by workers.
Researchers have compiled data on $682 billion worth of claims to look at the truth behind medical costs.
The laptop computer was taken from an unlocked treatment room “off of the inner corridor” in the hospital’s radiology department………….
Government punishes hospital with $850,000 fine……….
Hospital passes on the cost to consumers….……..
The fines for not having prepared a risk assessment will always be more expensive than quietly surrendering to extortion.
Symposium: Contraceptive mandate cases – why the Supreme Court will instruct lower federal courts to stop second-guessing religious beliefs : SCOTUSblog
By Drew Altman
Kaiser Family Foundation analysis of data from the Centers for Medicare and Medicaid Services and Truven Health Analytics showing that drugs account for 10% of U.S. health spending but 19% of employer insurance benefits.
This abbreviated video summarizes ten benefits strategy in three minutes:
By Bill Rusteberg
The McAllen Independent School District’s (MISD) self-funded health plan is administered by Blue Cross & Blue Shield (BCBS). BCBS traditionally utilizes their own proprietary managed care network and typically requires their network access exclusively as part of their bundled ASO services.