Rigged Insurance Contracts Bring Indictments / Guilty Pleas

September 27th, 2016

mullen1

In total, prosecutor Mark Roomberg said, the commissions resulting from the rigged contracts were “$2.5 million for the entire group.”

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Are PPO’s Saving Money, Or Costing Employers More?

September 27th, 2016

mulebriar

A Medical Bill Review audit of a large, 4,500 life employer group performed in 2016 exposes the truth about PPO “discounts.”

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Over 100 CIGNA Administered Plans Sued For Embezzlement

September 26th, 2016

flores

By Mark Flores

Just eight days after a federal court slammed CIGNA with a $13M judgement, 113 of CIGNA’s self-insured clients, along with their Plan Administrators have been named as defendants in a massive fraud lawsuit, alleging the plans “participated in a conspiracy and pattern of unlawful, reckless, and deceptive conduct to conceal an embezzlement and/or skimming scheme”.

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More Proof Reference Based Pricing Is Growing Market Share

September 25th, 2016

lemons

The following article illustrates the angst hospitals are undergoing in defending their indefensible and egregious pricing strategies through their PPO collaborators. The solution posed in this article by a hospital advocate is: Identify Reference Based Pricing (RBP) patients and don’t treat them! But that short sighted response brings on Cash Pricing strategies through companies like Asserta Health (www.assertahealth.com) which often times saves plan sponsors even more money than otherwise would have been paid hospitals under a typical RBP plan. Making lemonade out of lemons……………

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Insurance Consultant To Be Sentenced Wednesday, 28 September?

September 24th, 2016

haff

 

A 46-year-old San Antonio independent insurance consultant William O. Haff is facing up to five years in federal prison…. 

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California’s Health Care is 70% Socialized

September 23rd, 2016

california

This year, taxpayers will cover about 70 percent of what is spent on health care in California, according to a new analysis released Wednesday by the UCLA Center for Health Policy Research.

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TransparentRx – Elimination of Hidden Costs

September 23rd, 2016

 transparentrx

Most TPAs do not pass on the strong discounts for prescription drugs or do not have access to it. A quality TPA should be offering all prescription drugs at AAC + admin fee.

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Proceeding With Caution On Worksite Clinics

September 20th, 2016

pig“You can claim — and many do — that better access provides worthwhile value, but that’s akin to putting lipstick on a pig.” – Brian Klepper

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Illinois Extents Hep. C Treatment for Medicaid Recipients

September 20th, 2016

healthsity

If Medicaid allowed overseas treatment for Hep. C (Harvoni) the savings by utilizing a five star hospital system 495 miles south of Florida would save taxpayers 753 X ($95,000 – $19,000) = +$57 million...

For Information on Health City, contact Sarah Rusk, Health City Cayman Islands
t 345-640-4257  m 345-525-2131  healthcity.ky

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Which Physicians Generate The Most Money for Hospitals?

September 20th, 2016

doctor2

Primary care physicians presented the best return on investment for hospitals

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Apex Management Group Announces 4 Year Rate Guarantee

September 16th, 2016

apex

FOR IMMEDIATE RELEASE – September 2016
Apex Management Group (Oak Brook, Illinois) has announced a 4 Year Rate Lock on their APEX Suite of MEC Offerings. 

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Grand Theft Health Insurance

September 15th, 2016

theft

It is the Obama administration, and not the insurers, who perpetrated this heist….

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Would You Like Some Insurance With Your Insurance?

September 15th, 2016

gap1“After I got off the phone with him, I realized: That’s actually just insurance for my insurance,” she said, laughing.

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2016 Directory of Third-Party Administrators

September 13th, 2016

tpa12

See our detailed directory listing of TPAs, which includes their 2015 revenue, claims business by type and by volume, types of client managed and other contact information.

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Cost Plus Health Plan Guarantees No Balance Billing

September 13th, 2016

alliednationball“We guarantee no “balance bills” to our covered members for the amount taken as a discount from your provider’s retail bill.”

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Will England Eliminate 7 Day Health Care – Don’t Get Sick On Weekends?

September 12th, 2016

nhs

“16% more likely to die if they are admitted on a Sunday compared with a Wednesday” SOLUTION: Eliminate all health care services on Sunday…………..

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Healora – Cash Pay Health Plans Make Sense

September 10th, 2016

healora

Imagine being in control of your individual employee healthcare costs. Our low cost network puts you in control of your daily healthcare spend. You decide whether the employee is better off using existing insurance options or pre-paying for the specific procedure. Our pre-paid pricing is based on discounts of up to 70% and can save companies millions of dollars a year.

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Super TPA Purchases Maxor Administrative Services

September 9th, 2016

mulebriar

Texas Super TPA with growing market share is a  TPA worth watching…….

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Study: Chargemasters still drive up revenue at US hospitals

September 8th, 2016

lustig Victor Lustig

Just like sticker prices on new cars, no one ever pays hospital chargemaster rates. So why have them? A previous blog posting (Hospitals Dismiss Significance Of Chargemaster Prices?offers a possible reason, while the following article does too.

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Senator Addresses EpiPen Scandal

September 8th, 2016

confusedA pack of just two EpiPens costs more than $600 in the United States. To fully comprehend the outrage of this price, you must realize that the epinephrine included in the EpiPen costs less than $10 retail. And in Mexico it’s 25 cents (EpiPen alternative costs pennies in Mexico)

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How Employers Can Avoid Outrageous Health Care Overcharges

September 7th, 2016

life

Employers, adept at tracking business expenses, are surprisingly lax when it comes to double-checking healthcare costs.

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Farnsley Responds To Forbes Article

September 6th, 2016

farnsley John Farnsley

“We learn from history that we do not learn from history” – George Hegel

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Have PPO Networks Perpetrated The Greatest Heist In American History?

September 5th, 2016

heistUnderstanding the cost of health care is directly related to what we agree to pay, more and more employers are questioning managed care contracts upon which their health care costs are based. Many are discovering the truth for the first time.”

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EpiPen alternative costs pennies in Mexico

September 4th, 2016

outrageous

McALLEN — A life-saving medication that costs more than $600 in the United States is only a few cents in Mexico.

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California Passes Balance Billing Protection Legislation

September 2nd, 2016

surpriseCalifornia medical consumers will enjoy strong new protection against surprise out-of-network medical bills..………..

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Narrow Networks Growing More Common

September 1st, 2016

narrownetworksHealth insurers are limiting the physician and hospital options they offer through their plans. TRANSLATION: Insurers are limiting provider choice by eliminating providers who want more money than those willing to work for less.

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California Senate Approves Reference Based Pricing

September 1st, 2016

ben

“The bill would relieve patients from having to pay surprise medical bills out of pocket by requiring insurers to reimburse out-of-network doctors and other health providers a “fair amount” and doctors to accept the payments, said its author, Assemblyman Rob Bonta (D-Oakland).”

“That rate would be 125 percent of the amount Medicare pays for the same service or the insurer’s average contracted rate for the service, whichever is greater.”

Editor’s Note: If California passes this bill into law (very likely), Reference Based Pricing in California will take off in the private sector. No network plans, similar to what we have implemented in Texas since 2007, will have solved the problem of balance billing risk. And if Texas passes a similar law TPA’s like Caprock Health Plans and Continental Benefits, both of which administer Reference Based Pricing plans will achieve new business sales that will make Ben Feldman look like an amateur.

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Single Payer System Is Inevitable

August 29th, 2016

angryteacher

The following article is based on the premise that health insurance is health insurance. In truth, “health insurance” is not insurance at all but has simply become a government mandated welfare assistance program administered by insurance companies and TPA’s.

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Consultants Compete To Help Insurers To Manage Costs

August 29th, 2016

With ObamaCare in full swing, with little likely hood of meaningful repeal, insurers are targeting population management and statistical metrics to bolster a competitive edge and revenue…..

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Anchoring Health Care Pricing (See Previous Post)

August 28th, 2016

confusedHospitals have charge master pricing. Pharmaceutical manufacturers have AWP pricing. Consumers pay neither. These are simply made up numbers from which sellers “discount” their wares/services.

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Anchoring – What Car Dealers & Hospitals Have In Common

August 28th, 2016

aaaaaaaaaam

That first number thrown out there serves as an anchor — a first reference point. Every other price becomes an adjustment of that price. Take a hospital’s charge master rates for example………..

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When Should Patients Pay Cash for Prescriptions?

August 28th, 2016

cash-pay-model

Some consumers who pay far more than the cash price of a medication when using health insurance.

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8 Memorable Quotes About Hospital Prices

August 26th, 2016

fridge

“There’s more price transparency and quality transparency regarding a refrigerator than there is about your heart surgery.”

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Health Insurance Agents Turn To Begging

August 24th, 2016

beggar

Please Mr. Plan Sponsor, pay me direct. I really am worth it! I used to get $35,000 per year on your 75 employee life group plus an undisclosed bonus. I’m sorry I only showed up on renewal, and I promise I will change that. Please, Please, Pretty Please…………………

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Price Gouging Continues – Deep Pockets Targeted

August 24th, 2016

pockets

As long as health plans, with deep pockets, continue to roll over and play dead, health care costs will escalate to a point the entire health care finance system will implode.

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Health Care Pricing Transparency Drives Competitive Free Market

August 24th, 2016

albetross

Consumers Flee High Cost Hospital 

Texas General Hospital in Grand Prairie may be struggling to attract patients for elective services after a report named it the most costly hospital in the state, reports Dallas Observer.

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Largest Physician Owned Hospital in USA Expands Foothold

August 22nd, 2016

 

dhr12

Edinburg, TX–– Leaders at Doctors Hospital at Renaissance Health System (DHR) and Mission Regional Medical Center (MRMC) have signed a non-binding letter of intent (LOI) to explore collaborative opportunities between the organizations.

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Who Is Getting Rich from the Price of Prescription Drugs?

August 21st, 2016

moneyrich

Today, most drug companies offer large rebates to pharmacy benefit managers on behalf of different health plans and employers to reduce patients’ out-of-pocket costs. The problem is a significant portion of the savings is not being passed onto the public.

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PBM Exposes Industry Secrets on Specialty Drugs

August 21st, 2016

shellgame1The audience was aghast to learn that a specialty drug for Hep.C. earned PBM’s a 45% commission for one course of treatment………..

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Pascal Metrics Provides Patient Safety Analytics

August 21st, 2016

pascalmetrics

Pascal Metrics is the field leader in measuring and improving patient safety through advanced Patient Safety Analytics (PSA).

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Comrade Bernie Touts Medicare for All

August 18th, 2016

communitsSen. Bernie Sanders says the ability of Aetna to disrupt the public health insurance exchange system in 2017 by withdrawing from 11 states’ programs shows why letting private companies sell health insurance is a bad idea.

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BMA TPA Announces New Website

August 18th, 2016

bma

San Antonio, TX – Locally owned BMA (Third Party Administrator of Health Insurance plans) announced today that it has launched a new Web site along with enhancements to its End User Portal. Company officials are excited to make this upgrade to their Web site and enhance the user experience in their end-user Portal.

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Employers Look To Direct Health Care Contracting

August 17th, 2016

middleman1

Cutting out the middle man………………………..

Industry denials notwithstanding, reducing healthcare costs is fundamentally against nearly every healthcare organization’s perceived economic interests.

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Specialty Drugs – What Can A Plan Sponsor Do?

August 16th, 2016

bulletSpecialty drugs are bankrupting self-funded health plans. 

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Drug Crazed Elderly – America’s Other Drug Problem

August 16th, 2016

elderlydrug

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects.

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Texas School Districts – Insurance Fraud & Political Empowerment

August 15th, 2016

favor

“No problem Joe, I’ll make a call for you”

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Why You Can’t Find The Doctor You Need

August 15th, 2016

sorry

Some exchange plans are paying doctors less than Medicaid pays. Blue Cross in Dallas, for example, pays some doctors 10% less than Medicaid’s fee. If insurance buyers were forewarned, that would be one thing. But no exchange plan is advertising that access will be worse than it is for Medicaid patients.

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Health Care Statistics Between USA, England & Canada

August 14th, 2016

kinggeorge

King George III ruled England, Canada and what is now the USA. All three share the same language and are similar in many ways. But health care statistics show the USA a leader in health care delivery.

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Keeping Up with New Payment Models: “Cost Plus” or “Medicare Plus”

August 14th, 2016

newrealityProviders across the country are experiencing a new “reality” in payment models where patients are presenting “Medicare PLUS” or “Cost PLUS” insurance cards, the latest tactic of self-funded, commercial employee benefit plans.

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CFOs & HR Execs Facing Millions In Personal Liability Over Health Plans

August 14th, 2016

fiduciaryThe first shots across the bow have been fired highlighting how benefits leaders need to pay as close attention to health benefits as they have been paying to retirement plans.

“The Number One Hidden Cost for Plan Sponsors is Embezzlement of Plan Assets” – Bill Rusteberg

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Video Helps TPAs To Market Reference Based Pricing Plans

August 14th, 2016

rbpricingThis video is the second in a series and features a bold, fresh white board format to explain how a growing number of self-funded health plans are using Reference Based (or Cost Plus) Pricing to cooperate with area hospitals to agree on a pre-determined margin, thereby eliminating PPO networks.

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Hospitals Disposing of Organs, Refusing Transplants

August 12th, 2016

transplantorganFear poor outcomes yield worse federal performance ratings…….punishable by less Medicare funding to hospitals with lower ratings….. 

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Tenet Healthcare Terminates Humana Contract

August 11th, 2016
'You're fired, eliminated, laid off, let go, downsized, terminated ...'

‘You’re fired, eliminated, laid off, let go, downsized, terminated …’

Tenet Healthcare has notified Humana that as of September 30, 2016, Tenet Healthcare facilities and physicians will no longer be participating in any Humana provider networks.

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How Common Procedures Became 20 Percent Cheaper for Many Californians

August 11th, 2016

amazing

At a time when health care spending seems only to go up, an initiative in California has slashed the prices of many common procedures.

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Next President Faces Possible ObamaCare Meltdown

August 11th, 2016

thatcher

The next president could be dealing with an ObamaCare insurer meltdown in his or her very first month.

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BCBS Offers RBP Selling Tips

August 11th, 2016

Aug. 10, 2016

Tips for Explaining Reference-based Pricing to ASO Employer Groups

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Call To Action – Help Expose The Truth – Whistle Blowers Welcome

August 9th, 2016

mulebriar

Insurance insiders know the truth about undisclosed compensation paid to insurance agents, brokers and consultants by the BUCA’s. It is the industry’s best kept secret ( Health Insurance Consultant’s Best Kept Secret)

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Patient Held Hostage By Hospital Over $53,000 Bill

August 8th, 2016

hostage

Ms. Stinson had a 99 percent blockage of an artery, and her family was forced by the hospital to pay $25,000 before she could receive treatment, Ms. Stinson’s son-in-law told the Indy Star. A second blockage was discovered, and the hospital demanded $30,000 upfront before the second operation.

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Big California Firms Take On Health Care Giant Over Cost of Care

August 8th, 2016

boxing

Big California Firms Take On Health Care Giant Over Cost of Care

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Scheme Switches Medicare/Medicaid Patients to Private Insurance

August 7th, 2016

whydidntUnitedHealthcare says in its suit that American Renal Associates billed out-of-network prices of about $4,000 per dialysis treatment, much higher than the $200 paid by the Florida Medicaid program.

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McAllen ISD To Award TPA Contract – Proposed ASO Agreement Made Public

August 6th, 2016

missionimpo

Mr. Phelps of Mission Impossible

Your mission Jim, should you decide to accept it, is to review all documents to ensure best value for the McAllen Independent School District. As always, should you or any of your staff be caught or killed, the Secretary will disavow any knowledge of your actions. This pdf will self-destruct in five seconds. Good luck Jim.

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Proposed Form 5500 Changes To Increase Plan Sponsors Obligations

August 6th, 2016

shocked

It is clear that future Form 5500 reporting obligations will require more data, more resources and be subject to increased scrutiny by Federal agencies. Employer sponsors of group health plans should begin to evaluate plan documentation and the potential new disclosures required by Schedule J to ensure that each plan sponsor will be in a position to access such information and adequately communicate the new reporting requirements.

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Most Expensive Fairy Tale of The Modern Era

August 6th, 2016

fairytale

“The notion that insurance companies previously charged high premiums, or withheld coverage, from “high-risk” customers because they were evil and mean and greedy, but now Daddy Obama would make them see the error of their ways, was the dumbest and most expensive political fairy tale of the modern era.”

“The illusion of lower premiums today would be financed by higher tax bills tomorrow, and of course they’d never tell you they were raising your taxes to keep the ObamaCare scam floating. They’d tell you it was for bridges, or schools, or Social Security solvency, or something.”

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Deerwalk, A Powerful Tool For Plan Analytics

August 5th, 2016

Yes_Baby

Does your TPA use Deerwalk? Deerwalk is a state of the art system that will allow, among other things, a plan sponsor to compare PPO pricing against Medicare benchmarking on a real time basis. Plan sponsors, for the first time, can determine the real value of PPO “discounts”. Many will be shocked by the results.

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The ACA Medical Loss Ratios – “COST-PLUS” Health Insurance in Disguise

August 4th, 2016

evans

By Jeff Evans

I recently read an opinion piece that effectively summarized much of what many of us, in the health insurance and employee benefits business, have already figured out.”

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Managed Care – Cat Is Out of The Bag

August 4th, 2016

catoutofbagBy Molly Mulebriar

The best kept secrets of managed care are no longer the industry’s best kept secrets. The cat is out of the bag,

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Welldyn Sold – Will Super TPA Benefit?

August 4th, 2016

mulebriar

“The owner of Welldyn PBM and Continental Benefits has a vision to reduce health care spend in this country by 25%. With fresh capital from the sale of Welldyn, smart money bets Continental Benefits will become a national super TPA in short order. Before the Welldyne sale Continental Benefits was on a fast track. Now it will be nuclearized on an even faster track.” – Molly Mulebriar

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Narrow Networks = Balance Billing

August 4th, 2016

angrydoctor1

Narrow Networks Fueling Surprise Medical Bills and Fights Between Insurers, Providers and Patients

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Tenet Increases Reserve To Settle Kickback Allegations

August 3rd, 2016

tenetTenet believes it has reached an agreement in principle with the government to resolve the criminal investigation and civil litigation for $514 million.

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HealthCare’s “Brawl For It All”

August 2nd, 2016

boysfighting

“Woodrow Wilson once said “the seed of revolution is repression”.  Healthcare has operated on a model outside of free market forces, where consumers have paid the price, literally for decades. 

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BCBS of Texas To Drop 470 Kelsey-Seybold Physicians

August 1st, 2016

fired

Blue Cross and Blue Shield of Texas will sever ties with Houston-based Kelsey-Seybold Clinic, putting approximately 100,000 patients out of network with the providers’ physicians, the Houston Chronicle reported.

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Shrinking Networks

August 1st, 2016

freshberries

Reid Rasmussen

Insurance carriers know it. If you build self-funded plans, you know it. There are ways to reduce plan costs while ‘hiding’ the reduced benefits. One of the rapidly growing methods is to shrink the provider network.

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Are Insurers Ditching PPO’s?

July 31st, 2016
ppooInsurers that have been offering PPO plans in the healthcare marketplace appear to be cutting back on the number of offerings or eliminating PPOs from the marketplace altogether, leaving consumers with fewer options. Is this becoming an industry-wide trend?

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Offshoring American Health Care: Higher Quality At Lower Costs?

July 30th, 2016

medicaltourism

Is  the future of American health care 430 miles offshore? American health care providers are watching closely and anxiously.

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Ex-UnitedHealth CEO Raising $81 Million for New Insurance Startup

July 28th, 2016

brighthealth

Bob Sheehy, the former CEO of CEO of United Healthcare  UNH 0.76% , is back with a new startup called Bright Health.

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