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…………..
ERISA Class-Action Litigation over Fees in Health and Welfare Plans
December 13th, 2018Sales 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.
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………………………………………”
Rebates!
December 11th, 2018
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….”
Sierra-Berkshire Associates
December 11th, 2018
What Is AWP?
December 11th, 2018
It is an elevated drug price that is rarely what is actually paid……………So why use it?
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…………………………..
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?
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………….
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…………………
Tyler Man Connected To PBM Kickback Scheme
December 8th, 2018
Tom Slack, of Tyler, received more than $1.5 million in illegal kickbacks………………
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………………
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…………………………….
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……………
Guaranteed Cost Stop Loss Insurance
December 8th, 2018
RxReins
December 8th, 2018Bringing financial stability. Ensuring peace of mind.
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.”
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……………..
Wallet Biopsy Determines Prognosis
December 7th, 2018
Patients must be first class fund raisers – their lives depend on it…………………………
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…………………….”
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.
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.
Pigs To The Rescue…………………
December 6th, 2018
Pig hearts could soon be tested in humans after scientists pass important milestone…………..
Find Out If You Have Cancer in 10 Minutes
December 5th, 2018
Blood test to detect cancer within just 10 minutes developed by scientists
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………………………….
How to Bring the Big Health Insurers to Their Knees
December 4th, 2018
The American health care revolution is in full swing and growing………………….
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
Indemnity Insurance Plans Provide Best Coverage
December 4th, 2018
Plan liability is well defined and budgetable, patient liability is too…………….
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……………….
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.
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………………
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.
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……………..
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………………………………
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.”
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
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…………………….
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……………
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…………………..
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?
Nevada Wades Into National Debate About Association Health Plans
November 27th, 2018
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.
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…………………..
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?”
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…………………………..
Jenny & The Mexicats
November 22nd, 2018Cuero, Texas Home of The Turkey Trot
November 22nd, 2018Austin, Texas Sick Pay Leave Unconstitutional
November 21st, 2018
Judiciary says it’s unconstitutional, so legislators have developed a cure of their own………….
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.”
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…………………..
Ending American Greed?
November 21st, 2018
“The greed of the prescription drug industry is literally killing Americans and it has got to stop…..”
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?
BenefitMall
November 18th, 2018Merloch 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…………………………..
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……………..
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……..
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!
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…………………..
AWP – Ain’t What You Pay
November 14th, 2018
INSIDE AWP: THE ARBITRARY PRICING BENCHMARK USED TO PAY FOR PRESCRIPTION DRUGS
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…….
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……………….”
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.”
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…….”
Final Regs – Exemptions from Contraceptive Coverage Mandates
November 12th, 2018
Memorial Day 2018
November 11th, 2018
Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.
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…………….
Healthcare Waste is Costing Billions…………
November 10th, 2018
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…………………………
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…………………………………..
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……………………
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…………………………………….
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…………..
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……..
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.