Gaming The System

February 8th, 2016

gaming“The ability of employers to mostly evade liability is increasingly obvious………”

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Misappropriation of Healthcare Funding

February 7th, 2016

aaaaa

“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.”

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Doctor’s Conviction May Reshape How Doctors Handle Prescriptions

February 5th, 2016

doctorinprison

Doctor sentenced to 30 years to life in prison for the murders of three of her patients who fatally overdosed…………..

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Brand Name Drugs Inflation Rate 56% Over 3 Years

February 5th, 2016

belk David Belk, M.D.

“Market forces clearly have no effect whatsoever on the prices of brand name medications…………..”

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Do Your Assignment of Benefits Clauses Need a Checkup?

February 5th, 2016

assignmentofbenefits

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

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Cash Pay Plan Option Produces Significant Savings For Texas County

February 1st, 2016

asserta

Cash pay reimbursement strategies should be an integral part of any self-funded employee health insurance plan………..

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The Donald – Government Should Negotiate Rx Prices

February 1st, 2016

toodamnhigh

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……

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Government Mandates Sex Change Surgery

February 1st, 2016

obamawoman   “I am so relieved that I can now get the medical care that I have needed for so long,”

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Facts Suggest Hospitals & Insurers Agreed To Antitrust Scheme

January 30th, 2016

shocked

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………

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Are You Paying For A “Lexus” Surgery & Getting a Pinto?

January 29th, 2016

lexusMoney 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……………..

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Drug Shortages Causing Rationing – Public is Clueless

January 29th, 2016

rationbood

Prescription drug shortages are the new normal in American medicine. But the rationing that results has been largely hidden from patients and the public.

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Left Coast Voters To Consider Rx Cost Reduction Strategy

January 29th, 2016

california1Among the catalysts for public outrage are the sky-high price of treatments for diseases such as hepatitis C and the unapologetic markups for specialty drugs by former pharmaceutical executive Martin Shkreli.

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Your Next Insurance Agent Will Be A Robot

January 28th, 2016

robotA robot just gave your insurance agent a pink slip – doctors’ jobs are at risk, too…..

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Most Companies Shirk Fiduciary Duties When It Comes To Health Care

January 27th, 2016

bernieAn 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

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Florida Business Coalition Set to Revolutionize Health Benefits Purchasing

January 27th, 2016

whydidnt“How many businesses do you know that want to cut their revenue in half? That’s why the healthcare system won’t change the healthcare system.” Rick Scott – Governor of Florida

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

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Some Work-Based Health Plans Exclude Outpatient Surgeries

January 27th, 2016

fineLibbi 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.

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Reduce Health Care Costs 30% Through Level Funding

January 27th, 2016

levelfunded

Immediately reduce health benefits costs by $50K, possibly $250K or more……….

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Rampant Out-Of Network Provider Litigation Continues

January 26th, 2016

perrymason

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.

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ClearHealth Delivers Medicare-Based Pricing Programs

January 25th, 2016

Clear Health Strategies

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.

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BUCA Document Exposes Out-of-Network Reimbursement Strategies

January 25th, 2016

mulebriar

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 »

Working the “Spread” – Another PPO Revenue Stream

January 25th, 2016

mulebriar

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.

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PPO Requires Payment of Denied Claims?

January 22nd, 2016

confusedPPO agreement requires self-funded plan to pay certain claims that otherwise would be denied……………………..

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Cameron County Seeks Health Insurance Consultant

January 21st, 2016

hiringCameron County desires to enter into a contract with a qualified consultant……….

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Dear Bernie…………..

January 19th, 2016

canadafarm

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……….…………………

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The Murkey World of Actuaries

January 17th, 2016

odds1Harry Nostradamus

Actuaries ponder philosophical mutterings under the basis of implied thought influenced through critical thinking……………..

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Plan Sponsors: Prudent Business Practice Requires Actuarial Support

January 17th, 2016

riskassesmentDoes 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.

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Obamacare, Sign Me Up!

January 16th, 2016

screwed“ACA grace period could affect dental practices – Has your practice received calls asking for the return of third-party payments?”

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Take A Blood Test Or Lose Your Health Insurance

January 15th, 2016

needle1

Dale chose not to take his work-sponsored health assessment and biometric screening. His company responded by pulling his insurance coverage.

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Kashable – Group Credit Benefit Program

January 14th, 2016

kasableKashable’s alternative consumer lending program provides affordable credit to US employees through employers, PEO, payroll companies, private healthcare organizations and benefit exchanges.

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ObamaCare Fuels Growth of Concierge Medicine

January 14th, 2016

concierge

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.

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N.Y. Policy on Out-of-Network Medical Bills, a Model for Other States?

January 13th, 2016

newyork1

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.

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Aetna CEO Sees Humana Deal on Track to Close This Year

January 13th, 2016

lemon“Insurers say the combinations will give them greater leverage to control rising healthcare costs.” TRANSLATION: Insurers can squeeze more out of the lemon

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Drugmakers Raise Prices Despite Criticisms

January 11th, 2016

bang

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.

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McAllen ISD Reaches Out To 1,462 Insurance Consultants

January 10th, 2016

mulebriar

“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

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Beating Medical Trend – Managed Care vs Reference Based Pricing

January 10th, 2016

arrow

“Reference Based Pricing represents the last frontier in innovation to control health care costs in a tightly regulated and controlled market”– Bill Rusteberg

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Hand In The Cookie Jar?

January 10th, 2016

cookie

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…………

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Renting Medicare’s Provider Network

January 8th, 2016

 democratrepublican

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.

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AWP As A Rx Pricing Benchmark

January 7th, 2016

shellDue 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….

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Custom Design Benefits Announces Changes – True Cost Product Gains Momentum

January 7th, 2016

mueller Julie Mueller

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.

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Benestream – The Medicaid Migration Company

January 7th, 2016

benestream

“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?

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Employers Save By Moving Workers To Medicaid

January 7th, 2016

shocked

Companies shift insurance costs to the government….……….

Employers have not historically played a significant role in helping workers enroll in Medicaid……………..until now

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Swiss Re To Purchase IHC

January 6th, 2016

swissSwiss 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.

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Medicare: Big Changes Coming For Hip, Knee Surgery Payments

January 6th, 2016
'I guess I don't need to ask how your new hip is working out.'

‘I guess I don’t need to ask how your new hip is working out.’

“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.”

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Health Insurers Have No Reason To Reduce Price of Health Care

January 4th, 2016

confusedHealth 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.

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The Case of The Missing + 3%

January 3rd, 2016

What Do Three Men, A Hotel & A Third Party Intermediary Have In Common With Health Care Financing?

peopleIn 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…………………..

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Free Audit Lift Benefits Brokerage

January 1st, 2016

competitionA new company in town is shaking up local insurance brokers by offering to take a free look at what employers pay for benefits, to see if it can get them a better deal……………..

Competition breeds hostility in some people,” he said. “Bottom line: There aren’t any brokers who offer what we offer………….

 

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Tough Talk With Hospitals Ends In Missing Person Report

December 31st, 2015

mulebriar

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:

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What Will Be The Uber of Insurance?

December 31st, 2015

friendsuranceInsurance is ripe for disruption, and here are seven candidates that could revolutionize the industry much as Uber is upending travel.

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Large Political Subdivision Fails To Determine Best PPO Discounts

December 30th, 2015

mulebriar

Could this be a gifting of public funds with no basis upon which to determine best value?

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Continental Benefits – Stepping Outside The Box

December 29th, 2015

boxContinental 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.

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Plan Trustees Sue TPA for Breach of Fiduciary Duties

December 29th, 2015

shocked

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.

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Telemedicine Gaining Acceptance Among Patients, Insurers

December 28th, 2015

penskyPenske 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.

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Some U.S. Hospitals Mark Up Costs By 1,000%

December 28th, 2015

life

“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.

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Single-Payer Health Care On Colorado Ballot In 2016

December 28th, 2015

free1

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…..

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Allied National’s Provider Freedom Plan

December 27th, 2015

alliednationbalAllied’s unique Provider Freedom plan option  allows you to choose any health care provider without restrictions or penalties. There are no preferred providers or networks required.

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A Conflict of Interest For Doctors

December 27th, 2015

belk David Belk

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.

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Democrats Bash Health Insurance Companies

December 22nd, 2015

confused“The insurance companies, the drug companies, are bribing the United States Congress”

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Audit Claims? What A Novel Idea!

December 22nd, 2015

snooZe

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. 

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Arlington Healthcare Group

December 22nd, 2015

arlingtonAs former healthcare executives ourselves, we understand the challenges leadership faces to be successful in this fast-paced industry.

We use our industry expertise to help you develop and execute strategic plans that evolve your business.

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Most Shared Blog Entry for 2015

December 21st, 2015

linkedinThe most shared article on this blog for 2015 – Lawsuit Exposes Insurance Industry’s Best Kept Secret

December 19th, 2015

logo

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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A Picture Is Worth 1,000 Words

December 19th, 2015

DMN-hospital-graph-w-mpirica-quality-scores

(Click on Picture To Enlarge)

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? 

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Mulebriar Announces 2015 Award for Comment Excellence

December 17th, 2015

fox

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.”

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CEO Reviled for Drug Price Gouging Arrested

December 17th, 2015

martin

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.

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Cadillac Tax Delayed 2 Years

December 16th, 2015

cad

In the early hours of December 16, 2015, Congressional negotiators reached………….

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America’s Painkiller Epidemic Grips The Workplace

December 16th, 2015

zombie

New study claims that as much as 80 percent of employers face prescription drug abuse by workers.

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An Unprecedented Look At Medical Costs Nationwide

December 15th, 2015

​Researchers have compiled data on $682 billion worth of claims to look at the truth behind medical costs.

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Thief Steals Hospital Laptop, Government Punishes Hospital

December 15th, 2015

thief

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….……..

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Have You Done Your Risk Assessment, Doc?

December 15th, 2015

darrell

The fines for not having prepared a risk assessment will always be more expensive than quietly surrendering to extortion.

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Contraceptive Mandate – Second Guessing Religious Beliefs

December 15th, 2015

pope1

Symposium: Contraceptive mandate cases – why the Supreme Court will instruct lower federal courts to stop second-guessing religious beliefs : SCOTUSblog

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Employer Health Plans Pay Disproportionate Share of Prescription Drug Costs

December 15th, 2015

drugwsj

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.

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Why Health Insurance Is Now A Far Bigger Nightmare Than It Ever Was

December 15th, 2015

goodolddays

In the good old days health insurance was an irritant but not a nightmare. If you had high premiums, you had low deductibles.  And if you had high deductibles, you had low premiums.   Now we have high premiums and high deductibles.

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Ten Benefit Strategies

December 15th, 2015

This abbreviated video summarizes ten benefits strategy in three minutes:

https://www.youtube.com/watch?v=rMXukAf_4ok&feature=youtu.be

Insurers Forces To Compete Harder For Self-Insured Business

December 14th, 2015

selfunding More than 3 in 5 U.S. companies are self-insured, and self-insurance is almost universal among large employers……Roughly 60% of members at Aetna, Anthem and Cigna are in ASO plans

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McAllen ISD Enters Into Direct Contracts in Addition To BCBS Network

December 13th, 2015

wow

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.

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