Archive for April, 2013

Why Isn’t Your Employer Choosing Your Hospital?

Monday, April 29th, 2013

The creation of a true healthcare system in the United States will not be done by our totally dysfunctional Congress, nor government at any level.  As it turns out, the greatest influence for change may well be American corporations.


Why The Healthcare Industry Will Eliminate PPO Networks

Saturday, April 27th, 2013

“…This has led to the significant movement to eliminate PPO arrangements altogether as they not only provide no real value to the healthcare equation but in many cases promote a negative value…….”



Loyalty & Honesty In Health Care

Saturday, April 27th, 2013

“Loyalty and honesty are key to improving transparency in healthcare” by Matthew D. Rifkin, MD, was posted on Kevin MD today.

“From a patient perspective, the healthcare industry is a confusing, money-hungry monster that is supposed to be able to fix the illusive medical issues they face. They are operating in a state of flat out fear. Transparency in the system is a good start to helping patients sort through their emotions and confusion. This is why it’s important for physicians [and dentists] to enter the conversation that patients are having in their minds about price and quality.”

Dr. Darrell Pruitt

Cigna To Offer Telehealth Consultations

Thursday, April 25th, 2013

Cigna will begin offering telehealth consultations to  some of its members next year after reaching a deal with MDLive, a Florida-based  telehealth company.

Under the agreement, members of Cigna’s self-insured employer groups will  have access to 24/7 consultations, whether through online video, phone or email,  with more than 2,000 internal medicine, family practice and pediatric doctors  who work for MDLive. The consultations can address non-emergency issues,  including colds, rashes and headaches, MobiHealthNews reported.


Guest Blog Contributor Will Expose Little Known 2014 TPA Revenue Stream

Wednesday, April 24th, 2013

secret1    By Molly Mulebriar

2014 will bring a new and significant revenue opportunity for TPA’s. It will be legal, undisclosed and lucrative. A guest contributor, with many years of experience in the TPA business, has agreed to expose one of the best kept secrets in the TPA business. You will learn what TPA’s don’t want you to know. You will be  better prepared to evaluate your current TPA relationship. Will your TPA tell you the truth, or will you be purposely kept in the dark?

Editor’s Note: We expect our guest blogger’s article to be published here next week.

Colorado Passes Stop Loss Insurance Restrictions

Tuesday, April 23rd, 2013

The Colorado House of Representatives has approved legislation that would restrict stop-loss insurance sold to small employers.


New Website Will Disclose Health Industry Payments To Physicians

Tuesday, April 23rd, 2013

By Ankita Rao

April 23rd, 2013, 5:58 AM

For the first time, the government will make information about financial relationships between doctors, teaching hospitals and drug manufacturers publicly available.

To comply with a provision in the Affordable Care Act, drug and device manufacturers, along with group purchasing organizations, will have to disclose all of their payments and other compensation to physicians and teaching hospitals. Those who don’t comply could be fined.


Cost Plus Methodologies: Achieving True Cost Containment

Tuesday, April 23rd, 2013


From a financial perspective, the discount model employed by PPO’s is ineffective because a discount based on an inflated price does not provide effective cost containment. It is not anchored to the real cost of care. Rather, this outdated approach encourages gaming of the system as providers seize the opportunity to raise their prices disproportionately to their true costs in order to increase their “discount.”


UnitedHealthcare Provides Agent Compensation Overview

Monday, April 22nd, 2013

unitedhealthcareUnitedHealthcare relies upon a large network of independent insurance agents and consultants (collectively referred to as “producers”) to present our products to our customers. We believe it is important that our customers understand how these independent producers are compensated, so we offer this overview of our producer compensation programs.


Bait & Switch?

Sunday, April 21st, 2013

baitswitch“It is outrageous that a TPA/audit firm, who uses their own client’s buying power, will turn around and sell them access to a contract that is worse than Cost Plus, and as a result increase their net fees!”


Insurance Company Paid “Secret” Bonuses to Insurance Brokers

Friday, April 19th, 2013
The case revolves around allegations by Mercy that Aultman ‘bribed’ brokers with extra payments – in some cases, as large as $1 million – to persuade employer groups to switch to Aultman’s insurance plans, AultCare and McKinley Life Insurance.These payments weren’t disclosed to the brokers’ clients or on federal tax forms that non-profits must fill out to maintain their tax-exempt status, lawyers told jurors in court.

Why Are Some Employers Hell Bent On Keeping Grandfather Status?

Thursday, April 18th, 2013

horseRecently we met with a client to discuss PPACA and implications expected in 2014. During the meeting, the CFO said “Of course, we want to maintain our grandfather status!.”

“Why do you want to do that?” I asked. “Well, tell me why I shouldn’t!” replied the CFO.

My response went something like this: “We have discussed this before. I am surprised you don’t seem to “get it.” Do you want to continue to allow the government to handcuff you, immobilize you and subject your bottom line to ever increasing health care costs by prohibiting you from properly managing your plan using prudent business practices and keeping in line with your fiduciary duties?”

I reminded the CFO that ” a  White House health reform document lists many aspects of your current health insurance plan that cannot change if you want to keep grandfathered status. For example, you:

  1. Cannot Significantly Cut or Reduce Benefits.
  2. Cannot Raise Co-Insurance Charges.
  3. Cannot Significantly Raise Co-Payment Charges.
  4. Cannot Significantly Raise Deductibles.
  5. Cannot Significantly Lower Employer Contributions.
  6. Cannot Add or Tighten an Annual Limit on What the Insurer Pays.

These restrictions leave few, if any, ways to off-set the ever-increasing cost of health insurance. And, one thing everyone agrees on is that PPACA does little, if anything, to reduce the cost of health care. As of today, it appears that the only way to offset the rising cost of health insurance is to forego the option of grandfathering.

The CFO’s final response was “You haven’t sold me yet! I’m keeping my grandfather status!”

Editor’s Note: You can lead a horse to water…………………………


From an insurance consultant:

I agree. It seems that maintaining grandfather status is perceived as a good thing, yet most can’t tell you why. They might as well tattoo “Dumb Ass” across their forehead.

Democrats Beginning To Realize Magnitude Of Government Ineptness

Wednesday, April 17th, 2013
  • <p> Senate Finance Committee Chairman Sen. Max Baucus, D-Mont. questions Health and Human Services Secretary Kathleen Sebelius as she testifies on Capitol Hill in Washington, Wednesday, April 17, 2013, before the committee's hearing on President Barack Obama's budget proposal for fiscal year 2014. (AP Photo/J. Scott Applewhite)

    Senate Finance Committee Chairman Sen. Max Baucus, D-Mont. questions Health and Human Services Secretary Kathleen Sebelius as she testifies on Capitol Hill in Washington, Wednesday, April …more 17, 2013, before the committee’s hearing on President Barack Obama’s budget proposal for fiscal year 2014. (AP Photo/J. Scott Applewhite)  less

WASHINGTON (AP) — A senior Democratic senator who helped write President Barack Obama’s health care law stunned administration officials Wednesday, saying openly he thinks it’s headed for a “train wreck” because of bumbling implementation.

China’s Ghost Hospitals: A Hard Landing Ahead for China’s Health Care Reforms

Tuesday, April 16th, 2013

By Damjan Denoble

China is in the midst of a comprehensive $178.3 billion health care reform that is arguably the most ambitious among a series of stalled, largely counterproductive post-1978 efforts to improve access and reduce inequalities between rural and urban areas within China’s regionalized health care system. Unless the health care reforms are accompanied by a reform of fiscal policies, however, the absence of good governance brought on by financial constraints and perverse cadre payment incentives at the sub-national level is likely to undermine efforts to create a robust primary care infrastructure, and will consequently result in reform failure.


Health Insurers Expect More Employers To Self-Fund

Tuesday, April 16th, 2013


Health insurance executives expect U.S. employers to increasingly self-fund their group health insurance plans as a result of the Affordable Care Act, according to a survey released today by Munich Health North America, a subsidiary of Munich Re, one of the world’s largest reinsurers.

Among those surveyed, 82 percent have experienced a growing level of interest among employers in self-funding their group health insurance plans over the past 12 months, with nearly one-third (32 percent) stating that interest has increased “significantly.”


Top 50 Insurance Blogs

Tuesday, April 16th, 2013


TPA’s Invited To Participate In Lucrative 12% Charge Master Fee

Saturday, April 13th, 2013

12 percentIn a press release issued this morning, Homer G. Farnsworth M.D., unveiled a new business plan wherein interested TPA partners can participate in a 12% fee of gross billed charges on every hospital claim that comes through their doors.

“Our audit firm loves Charge Masters!” enthused Dr. Farnsworth. “Hospitals are our friends. Without them we would have to file for a Chapter 7. We approve and even encourage ever increasing hospital charges. It is not uncommon for hospitals to increase their charge master rates frequently, which of course, benefits us and our TPA partners!”

“Since our fee is tagged to gross billed charges, we don’t really care where a plan sponsor sets their reimbursment levels. It doesn’t matter to us, we get paid the same either way, which of course eliminates any accusations of conflict of interest competitors may level at us” stated Farnsworth in a question and answer session immediately following the press conference. “In fact, we don’t really care how thorough audits are, nor do we check them. We outsource almost all of our audits to various firms located here and there and everywhere. We take pride in being one of the best audit brokers in the industry!”

“Insurance brokers and consultants who consider placing business with us are encouraged to ask about our lucrative bonus arrangement on every hospital claim we audit. We promise total confidentiality – we believe in non-disclosure, afterall it’s NoneJa and it’s Swiss!”

TPA commissions are 25% of fees earned. This is in additiion to a TPA’s normal administration and revenue sharing fees with subcontractors such as PPO networks, stop loss carriers, subrogation, large case management outsourcing, etc.

“We have a case in South Texas that generated $900,000 in audit fees. The TPA earned a hefty $225,000 for doing nothing!” said Courtney Courthouse, Executive VP of Farnsworth Management  & Audit Company.

“No additional work was required, other than forwarding claims to a lock box in Georgia” added Dr. Farnsworth in between noon-hour cocktails.

For more information, contact  Homer G. Farnsworth, M.D. @


From a TPA:

Interesting post. Who starts your truck in the morning?






Sebelius Now Believes +2,000 Page Health Care Bill Too Complicated – Blames Republicans

Friday, April 12th, 2013

Chart-Tech Offers Repricing, Claims Auditing & Contract Modeling

Tuesday, April 9th, 2013


How Some Cost Plus Health Plans Are Structured

Saturday, April 6th, 2013

“Don’t bother doing something unless you are radically different from the competition. “

– Richard Branson


Cost Plus Audit / Legal Indemnification Fees Getting You Down?

Thursday, April 4th, 2013

“………… have a nagging concern about fixed costs. Audit fees seem high, exceeding claim administration fees. Your TPA is sharing in the audit fees, and perhaps your consultant/broker is too……..”


Repubicans Call For Increase Funding For ObamaCare

Thursday, April 4th, 2013

The only difference between Republicans and Democrats is that Republicans take longer to get there”

Editor’s Note: Remember 1966 when Medicare barely passed Congress? A majority of Republicans were against the bill. Now you can’t find a single Republican against it.


Walgreens Becomes First Retail Chain To Diagnose, Treat Chronic Conditions

Thursday, April 4th, 2013

It’s not just sore throats and flu shots anymore. Walgreens today became the first retail store chain to expand its health care services to include diagnosing and treating patients for chronic conditions such as asthma, diabetes and high cholesterol.


Perry Doubles Down Against Medicaid Expansion

Tuesday, April 2nd, 2013

6 Months Out – Will Federal Insurance Exchanges Be Ready?

Tuesday, April 2nd, 2013

By Robert Laszewski

As the Obama administration continues its top secret effort to build federal insurance exchanges in about 34 states while 16 states are doing it on their own ,(Will Federal Exchanges Be Ready)  that continues to be the big question.


Sex Change Coverage For Old Folks

Tuesday, April 2nd, 2013

 ” Please call me Helen”

Lawsuit Over Health Care Tax Could Kill ObamaCare

Tuesday, April 2nd, 2013

The Supreme Court upheld most provisions of the act in June, but Chief Justice John G. Roberts Jr. took pains in the majority opinion to define Obamacare as a federal tax, not a mandate. That was when the Sacramento, Calif.-based foundation’s attorneys had their “aha” moment.


India Rejects Patent Plea For Cancer Drug Glivec

Tuesday, April 2nd, 2013