Archive for November, 2012

Why Hospitals Are Afraid Of Suing Cost Plus Health Plans/Administrators

Friday, November 30th, 2012

“The Dallas team forced the dismissal by aggressively pursuing discovery deep into the recesses of the Plaintiffs’ billing practices. In the end, the Plaintiffs decided they preferred to dismiss the case rather than testify about the inner workings and methodology of their billing system and practices.”


Risk Managers Experience, Education Highlighted In New Study

Friday, November 30th, 2012

The National Alliance for Insurance Education & Research has released the first edition of “Risk Manager Profile: Knowledge and Responsibilities for a Growing Profession,” a study offering a look into the career paths and responsibilities of working risk managers.The study draws from a survey of nearly 500 risk managers as well as 10 in-depth interviews, the organization said Wednesday in a statement.The research is intended to help professionals compare their responsibilities and compensation with those of others with similar experience and education; longer interviews offer a look at how others began and made their way through the industry, the group said in the statement. The survey showed a wide variety of experiences, but Jim Cuprisin, research director for the National Alliance Research Academy, noted a few key findings: About 37% of risk managers have an advanced degree, which is above the norm, and about 88% of those surveyed were over 40 years old. “It takes awhile for people to move into the risk management field,” said Mr. Cuprisin, adding that many cross over from the insurance, financial and other industries.The study is available at The digital edition costs $45, and the print edition costs $55 plus shipping.

Mercer To Launch Medical Exchange For Medicare Eligible Retirees

Friday, November 30th, 2012

Mercer L.L.C. said it is launching a new health insurance exchange in which retired employees eligible for Medicare can choose from an array of different health care plans.While the prevalence of employers offering coverage to Medicare-eligible retirees continues to decline, about one-third still do, according to Mercer.Through an exchange, employers no longer directly offer coverage, relieving them of a significant administrative burden while giving retirees more benefit choices, Mercer notes. In addition, the exchange, which Mercer is offering along with Connextions, Inc., a technology solutions company, will provide assistance to retirees during enrollment periods and throughout the year.

New Employee Benefit – Ancillary Afterlife

Thursday, November 29th, 2012

Statistics show that about 80% of Americans believe in heaven. A clear majority, to be certain, but reason enough to provide a benefit allowing employees to connect to the afterlife?

One man is hoping it is. Robert Fahey, PhD., a self-proclaimed psychic spirit medium and clairvoyant, has been carving out a business niche for himself by working with employers to help workers reach out to deceased loved ones.

Not sure what you’d call this: Ancillary afterlife? Heaven benefits?

Whatever term you prefer, Fahey is building a decent client roster for himself, saying that intuitive knowing for workers about their future life translates into higher profits.

“Once a worker experiences the paranormal prescription of a spiritual message from the beyond or by way of an afterlife encounter, it delivers a boost in job competency skills, work interest, motivation, and kindness for the making of better communications and relationships,” Fahey says.

All things employers are after — particularly in today’s low engagement environment.

However, Fahey’s results don’t come cheap: According to his website, a one-time event costs $1,250 for a group of 2-10 participants, with an additional $125 per person charge for groups of 11 or more.




PPACA – Self-Funding, Direct Contracting Offers Effective Solutions

Wednesday, November 28th, 2012
Self-insured health plans, combined with stop-loss insurance to alleviate the risks associated with catastrophic claims, offer an effective solution to a large number of employers striving to be in compliance with the new law while continuing to offer health care coverage and keep costs under control.
The new health care paradigm revolves around provider accountability whereby groups of doctors, hospitals, and other health care providers collaborate to provide the full range of medical care for patients. This creates an environment in which the employer, not the insurance company, has the opportunity for direct contracting.

PPACA Update – Proposed Regs. On Wellness

Wednesday, November 28th, 2012

On November 20, 2012, the DOL, HHS and Treasury (Departments) jointly issued proposed regulations on wellness programs (2012 Proposed Regulations) reflecting changes made under health care reform that would:

  • Increase the maximum allowed reward for standards-based wellness programs offered in connection with a group health plan from 20% to 30% of the cost of coverage.
  • Further increase the maximum allowed reward for wellness programs designed to prevent or reduce tobacco use to 50%.


What If Success Sucks? Physician Establishes Non-Traditional Practice

Tuesday, November 27th, 2012

By Rob Lamberts, MD

“This could be big,” he said after I told him about the company who wants me to cover their 100+ employees.



Monday, November 26th, 2012

Section 1813(b) of the Act prescribes the method for computing the amount of the inpatient hospital deductible. The inpatient hospital deductible is an amount equal to the inpatient hospital deductible for the preceding CY, adjusted by our best estimate of the payment-weighted average of the applicable percentage increases (as defined in section 1886(b)(3)(B) of the Act) used for updating the payment rates to hospitals for discharges in the fiscal year (FY) that begins on October 1 of the same preceding CY, and adjusted to reflect changes in real case-mix. The adjustment to reflect real case-mix is determined on the basis of the most recent case-mix data available. The amount determined under this formula is rounded to the nearest multiple of $4 (or, if midway between two multiples of $4, to the next higher multiple of $4).

I don’t know about you, but this sounds to me like one of those problems where you are trying to figure out the time the westbound train leaving Philadelphia at 55 miles per hour will intersect with the eastbound train that leaves Poughkeepsie going 62 miles an hour. I am not sure which part of the public can understand this verbiage enough to comment, but I don’t want to have to sit next to them at a cocktail party. Just think what Rap Genius could do for these people! The inpatient hospital deductible would make sense and hundreds of confused phone calls could be avoided.

Lisa Suennen – The Health Care Blog.

Supreme Court Clears Way For New Challenge To ObamaCare

Monday, November 26th, 2012

The Supreme Court on Monday arranged for a Virginia university to go forward with new challenges to two key sections of the new federal health care law — the individual and employer mandates to have insurance coverage.


San Benito ISD Insurance Debacle Continues

Monday, November 26th, 2012


SBCISDFrustrations are beginning to mount concerning what one board member and several members of the community believe is the lack of an investigation into the San Benito CISD insurance letter debacle.


Dick Morris: Resist ObamaCare, No State Insurance Exchanges

Sunday, November 25th, 2012

Click Here To Sign The Petition To Refuse To Establish Health Insurance Exchanges!

States have until December 12 of this year to decide if they will set up the insurance exchanges mandated by the Obamacare Law. These exchanges will be the marketplace where health insurance is to be sold under the so-called Affordable Care Act.


955 Page Summary of 2,700+ Page PPACA

Sunday, November 25th, 2012

The government’s short, concise, Readers Digest Condensed Version of PPACA can be found at, a government sponsored website devoted to ObamaCare.

The latest summary of ObamaCare is found here:

Editor’s Note: This summary is over two years old but still on the government’s website. We are looking forward to publication of the Summary of the Summary. In the meantime, check this out –

The More One Looks At ObamaCare, The More It Looks Like Medicaid

Saturday, November 24th, 2012

Editor’s Note: Will ObamaCare require only one prescription per catagory to be covered at a minimum? Sounds reasonable to us. Need an antibiotic, ObamaCare will only cover xyz drug, otherwise you pay for it. And what about an employer who offers the minimum actuarial valued plan? How about paying 60% of Medicaid? Sounds go to us too. Narrow provider network? Hey, thay works for us! Need a colonoscopy, we will only pay if you go to Dr. Botchitup. Employers who want to keep their group medical costs as low as possible will need to explore these limits.

No One Seems Ready For ObamaCare

Friday, November 23rd, 2012

For industry outsiders, you need to know that a typical insurance company needs at least a year to plan and implement a new health insurance product. Guess what? They’re not going to get it.


Minimum Value Of Employer Sponsored Health Plan – Bonanza For Actuarial Firms

Friday, November 23rd, 2012

…..”employer-sponsored plans with nonstandard features would be able to generate an initial value using a calculator and then engage a certified actuary to make appropriate adjustments that take into consideration the nonstandard features.”

Editor’s Note: A self-funded employer who seeks to provide the minimum actuarial value of their health plan under ObamaCare will need to obtain an actuarial certification.

The Tiger Has No Teeth? Let’s All Go Naked!

Thursday, November 22nd, 2012
‘No individual, company, business, nonprofit entity, or health insurance issuer offering group or individual health insurance coverage shall be required to participate in any Federal health insurance program created under this Act (or any amendments made by this Act), or in any Federal health insurance program expanded by this Act (or any such amendment), and there shall be no penalty or fine imposed upon any such issuer for choosing not to participate in such programs.’

3 Ways ObamaCare Changed Tuesday

Thursday, November 22nd, 2012

“……….there are a few important changes that the Obama administration made Tuesday. Culled from the 333 pages of federal regulation, here are the three most important changes that happened….”


Boehner – ObamaCare Must Go

Wednesday, November 21st, 2012

“President Obama has won re-election, but his healthcare law is still driving up costs and making it harder for small businesses to hire workers. As was the case before the election, Obamacare has to go,” Boehner writes in the Cincinnati Enquirer.


Medical Provider Exposes Arbitriary & Obscene Health Care Pricing

Wednesday, November 21st, 2012

Hi Bill & Jeanne, First of all, Happy Thanksgiving.  I hope your holiday week is relaxing and meaningful.

Since you are my two colleagues/foot soldiers fighting for simplicity and truth in health care, I thought I would share the following.  Attached, you will see a bill for MRI services. (MRI bill2)  A student of mine gave me this bill for me to be a patient advocate and do some due diligence.  Unfortunately for him, he is going to have to pay the $1234.38 that is due.  This is because he has not met his deductible and Anthem responded back to the imaging center demanding that he pay that amount.  The problem is this:

The billed charges are arbitrary and obscene.  Similar to Bill’s fight with the “discounted PPO rates,” the $4367.47 that was billed is similar to the sticker price on the Toyota Camry sitting on the car lot.  Thankfully, this patient’s deductible was not higher, otherwise he would have been stuck paying much more.

This is an example of why patient’s need to be better consumers.  RPN charges $339.00 for CPT 70553.  Mink Radiology charged $3814.00.  That is a difference of $3475.00!  Or in other sobering terms, RPN’s discount is 91% when compared to Mink Radiology.

This patient also had another procedure done, CPT 70544 and was billed $1740.00.  RPN’s price is $249.00 resulting in a difference of $1491.00.

Now these “retail” prices that radiology companies use are artificial numbers because the insurance carriers negotiate much lower reimbursements.  For instance, for the two charges above, Anthem probably has negotiated a reimbursement of $500.00 for CPT 70553 and $400.00 for CPT 70544 and the radiology firms are happy to receive that.  However, if these radiology providers can inflate these charges, it impacts the patient’s wallet much greater via meeting their deductibles.  The entire process is rigged and patients need to wake up.

I admire the two of you for what you are doing and quite frankly, it makes me feel less alone in this fight.  For that, I am extremely thankful to have you both in my life.

Feel free to use this story, document as I blocked out the PHI.
Keep fighting!

Editor’s Note: Jeanne’s website is

Nixon Returns – Supports ObamaCare – Romney Defects To Democrats – Touts RomneyCare

Wednesday, November 21st, 2012

“Early last year, I directed the Secretary of Health, Education, and Welfare to prepare a new and improved plan for comprehensive health insurance. That plan, as I indicated in my State of the Union message, has been developed and I am presenting it to the Congress today. I urge its enactment as soon as possible. ”


Multi-Plan/PHCS Client Listing

Tuesday, November 20th, 2012

Phia Group Provides Regulatory Compliance Assistance

Monday, November 19th, 2012
Dear Reader,

The elections are over and regardless of who you voted for, the fact remains that PPACA is here to stay.  While many of you have been utilizing our firm to assist in your compliance needs, we have never publicly announced that our team of experts can assist your organization with Regulatory Compliance issues until now.

Our experts navigate the complexities of regulatory law as they relate to the health care industry. So, regardless of whether your inquiry relates to State or Federal regulation; issues involving State Insurance Departments, the NAIC, HHS, CMS, and DOL, our complance team can handle it.

Happy Thanksgiving everyone and make sure you work off those extra pounds in some way!

Adam V. Russo, Esq.


Don’t Write Off Employer Sponsored Health Care Yet

Monday, November 19th, 2012

“Turns out,” Galvin said, “the government wrote a pretty smart bill,” because “the government doesn’t want employer-sponsored insurance to go away … Someone’s got to pay for this.”………He added that even for employers who are tempted to pay per-employee penalties rather than provide health insurance, “the math really doesn’t work out.


Texas MedClinic Drops Blue Cross

Saturday, November 17th, 2012

Source: 1200 News Radio WOAI

“Access to care is going to become a problem”

by: Jim Forsyth

The Texas MedClinic chain of neighborhood emergency clinics today dropped Blue Cross Blue Shield of Texas from its list of accepted health insurance plans, effective later this month, in a glimpse of what the next major health care fight is likely to be, 1200 WOAI news reports.

“We were confronted with Blue Cross not increasing our fees significantly over the last five years,” Dr. Bernard Swift, the CEO of Texas MedClinic told 1200 WOAI news. “You can’t run a business when your costs increase, and your revenue doesn’t increase as well.”

Texas MedClinic has 14 locations in San Antonio, New Braunfels, and Austin, which treat minor emergencies and urgent medical illnesses. The company points out that it is a ‘quality and significant cost saving alternative’ to expensive hospital emergency rooms.

But Dr. Swift says insurance companies are trying to cut health care costs by cutting reimbursements to physicians. He says doctors offices are small businesses, with fixed costs for overhead, utilities, and staff, and he says the company simply can’t keep doing business with an insurance company which doesn’t properly reimburse physicians.

“Access to care is going to become a problem as more and more physicians reject what not only the federal government, but what private insurers, Blue Cross in particular, are attempting to do to physicians today,” he said.

Swift pointed out that Medicare and Medicaid are also cutting reimbursements to doctors, and much of Obamacare is predicated on reducing physician reimbursements.

He says all the insurance in the world isn’t much good if you can’t find a doctor who will accept it.

Visit for more information.

Create Your Own Medical Fee Schedules For Just $199

Saturday, November 17th, 2012

With a few clicks you can create medical fee schedules without government downloads or complicated formulas. Most users have mastered our software in 5 minutes!

Our customers include: physicians and other providers, office managers, insurance companies and other providers (HMO, PPO, TPA, PHO, IPA), CFOs, CEOs, CPAs, consultants, state and federal agencies, medical societies, associations, payers, billing services, accountants, actuaries, lawyers, life care planners and other healthcare professionals.

Phia Group Consulting – Time For Procrastination Is Over

Saturday, November 17th, 2012

“Let’s face it…” The Phia Group’s CEO Adam V. Russo, Esq. stated, “The Patient Protection and Affordable Care Act is here to stay.  The only question we need to ask is whether we will rise to the challenge, or collapse under the regulatory burden.”


Get Ready To Pay More For Your Grand Slam

Friday, November 16th, 2012
A Florida restaurateur who operates roughly 40 Denny’s locations and five Hurricane Grill & Wings franchises in Florida, Virginia and Georgia intends to add a 5 percent surcharge to customers’ bills to offset costs from ObamaCare beginning in January 2014 when the Affordable Care Act is fully implemented.


TPA Markets Medicare Plus Reimbursment Plan

Wednesday, November 14th, 2012

This is another example of a TPA moving away from managed care contracts and reimbursing providers using Medicare pricing as a claim benchmark.

Plan pays 125% of Medicare. Plan participants can log in on their smart phone while at the providers office and key in the procedure code. “Excuse me nurse, what is the procedure code for that lab test you want me to take? Oh, $500 you say? Well, my plan will pay $200 for that test, will you accept that as payment in full?

That will be  almost like in the old days, around 1966 when I twisted my leg while in pole vaulting practice. My mother took me to the doctor and before any treatment was tendered, my mother asked “What will this cost?” A simple, direct question. “It will be $15.” Ok, I can afford that, will you take a check?”

Call For Speakers

Wednesday, November 14th, 2012

 Do you have a session concept you feel would add value to the 26th Annual Benefits Forum & Expo program? We are accepting speaker and session proposals for this program until December 13, 2012.

Submit Your Proposal Here

Employer Based Health Care Plans No Longer Dominate In California

Wednesday, November 14th, 2012

Instead of relying on work-based insurance to pay for doctor’s appointments and hospital visits, Californians leaned heavily on government programs for low-income families.


ObamaCare: Bad For Insurers, Great For Hospitals

Tuesday, November 13th, 2012

     (Bloomberg) — HCA Holdings Inc. and other hospitals will get more paying customers while insurers like UnitedHealth Group Inc. will see profits squeezed as President Barack Obama moves to preserve the health care overhaul he championed.


Did The Election Save ObamaCare?

Tuesday, November 13th, 2012
There are six major flaws in ObamaCare. They are so serious that the Democrats are going to have to perform major surgery on the legislation in the next few years, even if all the Republicans do is stand by and twiddle their thumbs.

With ObamaCare Now A Reality, Employers Choose Strategies

Tuesday, November 13th, 2012

    “This is here to stay,” said J.D. Piro, a senior vice president at Aon Hewitt who leads the company’s health law consulting group. “I’ve been saying for a couple of years this is by and large an entitlement program, and entitlement programs are very rarely repealed. They can be amended or changed around the edges. But it hasn’t been overturned in court or at the ballot box.”


What Does The Election Mean For ObamaCare?

Friday, November 9th, 2012

If the election had turned out differently, it would have been easier to repeal Obamacare. But that does not mean that Obamacare is here to stay. The only difference is that dismantling it will now be a more protracted and messy process.


Risk Manager Reinstated

Friday, November 9th, 2012


SBCISDSan Benito CISD Superintendent of Schools Antonio G. Limón elected to reinstate Janie Gonzalez to her former position of risk manager with the school district on Tuesday morning.


Cost Plus Health Insurance Sales Will Explode in 2014 – Opportunities Abound

Thursday, November 8th, 2012

Under ObamaCare, the year 2014 will be pivitol. All citizens  (except a select few) will be required to purchase health insurance or face punishment.  However, like mandatory auto insurance in Texas, many will just ignore the law and spend their money on more useful things. After all, the IRS cannot enforce the individual tax under PPACA.

Employers with 50 or more employees though, cannot ignore or dodge ObamaCare. They are going to pay for something, either in benefits or in punishment taxes, or a combination of both.  IRS enforcement will be stringent and aggressive.

So where is the relief for employers with 50 or more employees who will be facing stiff increases in health care costs? What can an employer do to minimize costs and stay off the radar screen from federal enforcers?

There are several strategies to be employed. (1). Directed health care – employer steerage of medical care through carefully selected and directly contracted providers (2). Charge employees  the maximum 9.5% of gross income as allowed by PPACA towards the cost of group health insurance (3). build a benefit plan that provides the minumum 60% actuarial benefit value (4). pay hospitals and other health care facilities their cost as reported to CMS plus a margin (profit) or Medicare rates, whichever is greater.

The unintended diamond in PPACA is that ObamaCare does not dictate that all providers must be covered nor does ObamaCare dictate how much a provider must be paid. To pay a hospital 100% of Medicare, for example,  is less than paying typical managed care rates. Hospital executives are sucking eggs these days.

It is our opinion that implementing these four strategies will reduce an employers health care costs by as much as 60%.

Cost Plus Health Insurance will gain rapid market acceptance in the next 18 months. We expect to see hybrids tied to high deductible plans and cash savings accounts. Those with the foresight to recognize and seize opportunities in this cottage industry will join the ranks of  a new class of rich people, much to the pleasure of Democrats seeking additional revenue sources.

Interesting stuff Bill! The law of unintended consequences. But what about us individual policy holders? Any opportunities there?

ObamaCare – Path To Compliance (Or Prison)

Thursday, November 8th, 2012
Now that ObamaCare is firmly in place and there is absolutely no hope now that it will be overturned or modified to any significant degree, we must all plan accordingly. Only 13 months from now will we will begin to see major changes to take effect.
Attached is an excellent piece from Findley Davies (Path to Compliance) which clearly outlines the timeline and mandates we are required, under threat of punishment, to adopt and implement. path to compliance with detail
Editor’s Note: More manufacturers will be moving offshore to avoid increasingly stringent government mandates.

Long Time Insurance Professional Runs For City Council

Monday, November 5th, 2012

Clarence Brown is a United HealthCare representative from the Austin, Texas area. We like his message of fiscal responsibility and wish him success tomorrow.

We hope Scott Brown of Mass. does well too.


Future Of Health Reform May Turn On Senate Races

Monday, November 5th, 2012

While all eyes focused on the presidential race, the ultimate fate of the Affordable Care Act (ACA) could depend on the Senate contests in the states.


United HealthCare Takes Over Risk Adjustment Function From Uncle Sam – A Conflict of Interest?

Monday, November 5th, 2012

If an insurance company had influence over the information technology architecture used to run the exchange, it could interpret federal standards in a way to exclude competitors or make it more difficult for them to win approval, say some insurance experts. Or it could have an inside track on knowing how to design plans that meet the standards.


Post Election Flood Of ObamaCare Rules Expected

Monday, November 5th, 2012

The once-steady stream of regulations and rules from the Obama  administration — instructions for insurance companies, hospitals and states on  how to put the law in place — has slowed to a trickle in recent months in an  attempt to avoid controversies before the election.  Get ready for post election flood of rules and regulations……………)


More Employers Moving To High Deductible Plans

Monday, November 5th, 2012
There’s a good chance during open enrollment this fall that you will be offered a high-deductible insurance plan with a savings account — if you haven’t already been nudged into one.

Flash Gordon Inspires Molly Mulebriar

Sunday, November 4th, 2012

Molly Mulebriar, ace forensic investigator and former Rhodes Scholar reports that Flash Gordon is back! Working incognito, disguised as an insurance consultant, Gordon scored big in bringing a Texas county’s self-funded medical plan back on course. (See –

Seeking to stem a $1.2 million annual hemmorage without reducing or eliminating benefits, Flash Gordon did the impossible………through innovative strategies and high testosterone levels shared jointly with Commissioners Court, Flash improved benefits, kept funding static (we assume)  while projecting a savings to the county in the coming plan year.

The local newspaper reported:

“The (county) judge was very, very clear… He would like not to cut benefits; he would like that the hospitals, the doctors, and county commissioners get along,” Gordon told the court regarding this year’s quest to find the best proposals. Gordon said although a lofty goal, he is pleased to announce that they were able to accomplish that.

Mulebriar writes: “As a head fake, Gordon added completly useless  aggregate insurance coverage as well as a fully-insured, potentially commissionable  transplant policy.  Dr. No, local naysayer, applauds this diversionary tactic.”

According to Mulebriar, moving away from managed care contracts was Gordon’s only sensible strategy (other than recommending the county terminate their group medical plan). “Direct contracting with the local hospital was brilliant” Mulebriar panted in excitement as she filed her report. “In addition, paying other facilities on a cost plus basis  (see ) will certainly lower the county’s cost” she explained to our incredulous staff during Friday afternoon’s Martini Brunch. “Just look at what the Corpus Christi Independent School District was projected to save had they done the same thing! Lack of testosterone killed that deal it seems.”

Embarking on our third round of martinis, and on a roll, Mulebriar offered “One would hope, we suppose, that plan participants will seek care at the cost-plus hospitals instead of the locally contracted hospital to keep the county’s cost as low as possible for the coming year.”

Editor’s Note: Molly Mulebriar is currently investigating a recent public bid for group medical insurance that may expose bid law violations and tortous interference, slander, boycott and unfair trade practices.



Surgery Center Network

Friday, November 2nd, 2012

The health care delivery system continues to evolve and adapt, despite (or because of)  an ever changing political climate.

In our opinion ObamaCare is the best thing that has happened to our health care delivery system and is as dynamic to the market as was the ship owners in London  who established Lloyds  several hundred years ago  – it has “upset the apple cart”, fundamentally  releasing a dormant, energizing drive among the private sector to provide competitive solutions based on the principle that a good product  fullfills needs common to most at a reasonable profit supported by consumers who perceive value.

Surgery Center Network seeks to provide competitive and transparent pricing –


Groups Urge Pricing Transparency In Health Care

Friday, November 2nd, 2012

So far, 10 organizations—including the Colorado Business Group on Health, the Leapfrog Group, the National Business Coalition on Health, the National Partnership for Women & Families and the Corporate Health Care Coalition—have endorsed CPR’s statement, which lays out two expectations: first, that by January 2014, providers will not restrict health plans from making price and quality information available for use in transparency tools (MANAGED CARE CONTRACTS PROHIBIT PRICING DISCLOSURE – WILL THAT NECESSARILY CHANGE?) , and second, that by the same time, health plans will give self-insured customers full use of their own claims data (TEXAS HOUSE BILL 2015 ON STEROIDS!)