Archive for July, 2013

Cost Shifting In Reverse?

Wednesday, July 31st, 2013

holyBy William Rusteberg

Some providers exclaim “we have to pass our losses from Medicare, Medicaid, and uninsured patients to the private sector to stay in business. Otherwise, we would go broke!”  This cost shifting  excuse has been the Holy Grail for 30 years now. And no one has ever really questioned it.

Almost any hospital administrator  (or any other medical provider) you ask will say they lose money on Medicare patients. So why  then do most providers accept Medicare? They don’t have to. They are not required to. The fact is, efficient hospitals earn a profit from Medicare.  After all, Medicare calculates on a cost plus reimbursement basis.

And, if it is true that providers  lose money on Medicare reimbursement rates, why then do they sometimes accept rates below Medicare through managed care contracts?

Here is an example: $2,300 = $1,500 cash price = $572 Medicaid reimbursement = $497 Medicare reimbursement = $400 XYZ Insurance Company reimbursement. These are actual pricing through a provider  (who asked to remain anonymous) for an  out-patient MRI.

“That’s right Uncle Herrmann, the provider’s billed charge is $2,300 ( a meaningless number no one ever pays) yet  accepts differing amounts depending on the payer. In this example, an insurance company has negotiated a rate that is less than Medicare.”

It seems that health care prices are much like airplane tickets. Next time you fly, ask those around you how much they paid.  You may be surprised that not all paid the same. Some paid more, some paid less. If you find that you are subsidizing your seat companion’s ticket, make sure he or she thanks you. The lesson here is, don’t get upset, get informed.  You will be better prepared to negotiate a savings the next time you travel. The same applies to health care financing.

A fellow revolutionary said today “you say cost shifting was caused by the government with the introduction of Medicare in 1966. But who really cost shifted? Wasn’t it the payers seeking increased revenue? The notion that the government caused cost shifting is misplaced and unfair! In fact Bill, we have documented that some providers accept less than Medicare.”

So it must be agreed that cost shifting has occurred. But was it shifted to the taxpayers, or private payers? You decide.



Montana’s State-Run Free Clinics Sees Early Success

Wednesday, July 31st, 2013


Montana opened the first government-run medical clinic for state employees last fall. A year later, the state says the clinic is already saving money.

Montana opened the first government-run medical clinic for state employees last fall. A year later, the state says the clinic is already saving money.


WellPoint Exects $20 Billion PPACA Windfall

Wednesday, July 31st, 2013

Obamacare is already making insurance giant WellPoint feel a whole lot healthier.

WellPoint trumpeted that good news during an analyst conference call last week to discuss second-quarter results. Not only did its quarterlyresults beat analysts’ expectations, but newly minted CEO Joseph Swedish said the company expects a windfall of sorts from the Patient Protection and Affordable Care Act — as much as $20 billion by 2016.

Some on Wall Street arched an eyebrow at that one. “Pretty bullish,” said one, who doubted Wellpoint’s ability to grow so far, so fast. But Swedish, though clearly labeling his projections as just that, insisted they were realistic.

Swedish based his optimism on estimates that 25 million more U.S. residents who now go without health coverage will have it by 2016. As Medicaid opens its doors to more middle- and lower-income folks, Wellpoint expects millions to secure some type of coverage through the state insurance exchanges. And Wellpoint will be offering that insurance, though its Blue Cross Blue Shield licensees, in at least 14 states.

“Over the next few years, enrollment growth in Medicaid, exchange and other products could drive our annual run rate operating revenue to around $90 billion by 2016,” Swedish said during the conference call.

Swedish told the analysts that surge will offset another trend spotted lately, one in which fewer small businesses are purchasing employee coverage. To what degree the one will offset the other, no one yet knows, said Wellpoint CFO Wayne DeVeydt.

“Until the exchanges are up and running, it’s a challenge for us to be overly optimistic, but we are optimistic about our future,” DeVeydt said.

However, again, this plunge in small business plans may be fueling the exchanges, as small businesses direct their employees there for coverage. Some large corporations are expected to follow the same course as they seek to reduce their exposure to the vagaries of fully insured coverage for their workers.

Reference Based Pricing Gaining Popularity

Tuesday, July 30th, 2013
Reference-based benefits are becoming popular as it becomes easier to compare costs for the same service, Lenko said. He said when employees know how much services cost, and they are sharing in that cost, they become more engaged with their health care. “The patient becomes a better consumer,” Lenko said. “The more they shop for their own health care, the more efficient they will be.” (more…)

Dental Insurance Does’t Exist – Don’t Be Fooled?

Sunday, July 28th, 2013

By D. Kellus Pruitt DDS


Downey, California dentist John McCallister DDS has produced a splendid video which blows apart myths which keep dental “insurance” companies in business. The more appropriately called, “discount dentistry brokers” – who casually hide dentists’ concerns – simply cannot survive transparency.

The Video:


Good News For Captives

Friday, July 26th, 2013

WASHINGTON, D.C. (JULY 25, 2013) BY MICHAEL COHN Senators Tom Harkin, D-Iowa, and Chuck Grassley, R-Iowa, led a bipartisan group of five senators in introducing legislation to increase the alternative tax liability limitation for small property and casualty insurance companies. The small companies targeted in the proposed legislation mostly serve rural communities, such as those in Harkin and Grassley’s home state of Iowa, which rely on alternative tax liability adjustment to provide additional surplus and cash flow use to pay their customers’ insurance claims. Currently, property and casualty insurance companies with annual premiums above $350,000 but less than $1.2 million can elect to be taxed on their net investment income as opposed to their annual operating income. The Small Mutual Inflation Update bill they introduced Tuesday would adjust the eligible premium index for inflation—for the first time since 1986—to $2.012 million, increasing the current maximum limit and indexing it to inflation thereafter. “Put very simply, this legislation will benefit Iowa’s small insurance companies,” Harkin said in a statement. “These companies have served Iowa communities for decades, and are an integral part of Iowa’s economy. I hope that the Senate Finance Committee will adopt this commonsense proposal as they move forward on tax reform in the coming months.” The legislation was cosponsored by Senators Roy Blunt, R-Mo., Amy Klobuchar, D-Minn., and Jay Rockefeller, D-W. Va. “Some thresholds in tax law aren’t indexed for inflation, and that means they become outdated,” said Grassley. “Our legislation updates a key threshold for small insurance companies so they can continue serving their rural customers. This legislation helps to ensure that small mutual insurance companies will continue to be able to serve rural residents who have unique circumstances, such as living far from a fire station, and so are often unable to obtain private property insurance through traditional insurance companies

Eight Things. You Need To Know About ICD-10

Friday, July 26th, 2013


The massive ICD-10 change is quickly approaching, and it affects all of us in the healthcare field. Thus, there is no time like the present to start your ICD-10 education. Here are the eight things you need to know now about ICD-10.


Dead Horse Strategies

Thursday, July 25th, 2013

(Library of Congress/Alfred Waud)
“If the horse is dead, painting its toenails or calling it “living impaired” is not going to bring it back to life.”

Sometimes It’s Tough To Get An Underwriter To Quote

Thursday, July 25th, 2013


Brownsville Independent School District had a tough time this year in procuring liability cover. Could Board of Trustee behavior be the reason? See (Start 1:04, end 15:05)

United HealthCare To Increase Accountable Care Contracts To $50 Billion By 2017

Wednesday, July 24th, 2013

UnitedHealthcare will significantly expand its already substantial base of accountable care contracts over the next five years across our employer-sponsored, Medicare and Medicaid health benefit businesses, helping transform how health care is delivered, paid for and rewarded.


On-Line Diagnosis Before Doctor Visit?

Wednesday, July 24th, 2013
Faced with know-it-all patients who go online to diagnose themselves, several doctors’ organizations have come up with sanctioned online symptom checkers so patients can do some sleuthing. Laura Landro and Jason Maude, Isabel Healthcare founder and CEO, join Lunch Break. Photo: Getty Images.

Once Entitlements Begin There Is No Turning Back

Wednesday, July 24th, 2013


The administration will mount a huge public relations campaign to highlight individuals who have received government assistance (welfare) to help them afford, say, chemotherapy, or dialysis, or some other life-saving treatment. Will Republicans (politicians wanting to be re-elected) advocate cutting off the funds that help pay for such care? The answer is no.


CCHF: Stay Away From Exchanges – Refuse To Enroll!

Wednesday, July 24th, 2013

A nonprofit group wants to persuade Americans to stay as far from the Patient Protection and Affordable Care Act exchanges as possible.


Government Shutdown Looms Over ObamaCare

Wednesday, July 24th, 2013

ObamaCare is at the center of a rapidly escalating fight that threatens to  shut the government down this fall. [WATCH  VIDEO]

Senate Republicans, including two members of the leadership, are coalescing  around a proposal to block any government funding resolution that includes money  for the implementation of the 2010 Affordable Care Act.


Hospitals Face A Self-Inflicted Wound

Tuesday, July 23rd, 2013


When the Obama administration was selling the benefits of the Affordable Care Act in 2010, the hospital industry agreed to accept a $155 billion decrease in Medicare payments over a decade. The administration assured hospital executives that patients newly covered under the health-care law would make up for much of the loss. Because of the ongoing squabbles between President Obama and Republicans in Congress over the U.S. budget, that hasn’t happened.


Oklahoma Surgery Center’s Pricing Transparency Sparks Price War

Tuesday, July 23rd, 2013


A surgery center in Oklahoma City that is dedicated to complete price transparency is apparently sparking a price war among some providers in the region, reported KFOR-TV.

The Surgery Center of Oklahoma began posting prices for about 100 procedures in 2009. The prices include all related services, such as anesthesiology.

“When we first started we thought we were about half the price of the hospitals,” Steven Lantier, M.D., the Surgery Center’s co-owner told KFOR. “Then we found out we’re less than half price. Then we find out we’re a sixth to an eighth of what their prices are.”

According to KFOR, at least five other facilities in Oklahoma now post prices, although they all cater to specialty care, such as oncology or cardiac care and imaging. None of the state’s acute care facilities post prices.

In an interview with FierceHealthFinance last year, G. Keith Smith, M.D., surgery center anesthesiologist and co-owner, said he intended to keep prices reasonable in order to encourage people to pay for them out of their own pockets. He also wanted to post prices to pressure competing hospitals to engage in more price transparency.

However, the Oklahoma Hospital Association (OHA) does not believe price transparency will migrate to its membership in the near future. “Where we can reveal information that’s meaningful to the patient, we very much support that; that’s what hospitals need to do,” OHA President Craig Jones told KOFR. “The difficulty when you compare hospitals with surgery centers is that surgery centers, most of the work they do are elective procedures, which are a bit more predictable.”

To learn more: – read the KFOR report

Detroit Wants To Unload 19,389 Retirees Into ObamaCare Exchanges

Monday, July 22nd, 2013


A good chunk of Detroit’s debt problem is a health-costs problem. The Detroit Free Press notes that the city has $5.7 billion in unfunded retiree health-care liabilities, nearly a third of the city’s debt.

For this problem, at least, Detroit appears to have a relatively straightforward solution, one that hasn’t been available to bankrupt cities in the past. It plans to transition its 19,389 retirees into the health law’s new marketplaces, saving the city somewhere between $27.5 million and $40 million annually.

This isn’t a policy that cities need to go into bankruptcy to execute; there are many that are struggling with the costs of retirees’ pensions and health benefits. One report from the Pew Center for the States looked at 61 cities across the country and found that, taken together, they had $126.2 billion in health benefits promised to retirees. Only 6 percent of that amount – $8 billion – currently has funding.

retiree bills


Caprock Health Group Announces Addition Of Bob Brennan As Vice President Of Operations

Monday, July 22nd, 2013

Lubbock, TX/San Antonio, TX – July 22, 2013 – The Caprock Health Group is pleased to announce the addition of Bob Brennan as VP of Operations.  Mr. Brennan’s hiring is part of the Caprock Health Group’s ongoing strategy to expand its market presence and attract the most-talented and experienced professionals.  In this role Mr. Brennan will be responsible for all aspects of plan operations for both the Lubbock and San Antonio operations centers of the companies.

Prior to joining Caprock Health Group, Mr. Brennan has held key executive management roles related to plan operations with various organizations in the industry.  He is an expert in metric driven management and process oriented applications related to self-funded health plan services.  He has more than 25 years of industry experience and has built his career on the basis of superior customer service and high quality, effective claim operations.

As a new member of the Caprock Health Group, Bob will be an integral part of the executive management team and will help further solidify the company’s position as an industry leading health care services organization.

About Caprock

Caprock Health Group is a health care services organization comprised of affiliated companies working in close coordination to provide an effective integrated solution for employers and insurance brokers who want the very best in self-funded health plan management and fully insured plan access.  Caprock Health Group offers a full suite of products which are designed to provide each employer maximum cost savings.  Our focus is helping employers manage long-term health care costs by empowering employees through education, creating healthier consumers, and incorporating highly effective cost containment strategies.

For more information contact:

Annette Alonzo

Director of Marketing






Caprock Health Group Acquires Verity National Group

Monday, July 22nd, 2013


Lubbock, TX/San Antonio, TX – July 22, 2013 – Caprock Health Group announced today that it has completed the acquisition of Verity National Group, an established health plan services company based in San Antonio, Texas.  The acquisition makes Caprock Health Group one of the largest health care services organizations in the region.

The acquisition will continue Caprock Health Group’s strategic initiative related to geographic expansion, product diversification and growth.  The merger of Caprock and Verity will enhance the Caprock Health Group’s position as an industry leader in innovative plan management and cost containment services.

“Verity is a great complement to the Caprock organization from many perspectives.  They have a strong team of experienced staff and great leadership who know our industry and have a history of successfully serving agents and employers in the areas of self-funded plan administrative services, care management services, ancillary product services and online eligibility/consolidated billing,” said David Adams, CEO of Caprock Health Group.

Mr. Adams said a component of the current Verity operation, specializing in eligibility management and related technology services, will continue to be marketed under the Verity nameplate by Caprock.  He said Laurie Burke will remain the President of that Verity unit, and also will serve the Caprock Health Group as a Senior Consultant.

Ms. Burke said, “We’re honored to be a part of the Caprock enterprise.  Together, we offer the broadest range of services in Texas and the Southwest.”

About Verity

Verity National Group has provided insurance services from its Central Texas base since the late 1980s.  The firm serves a mix of carrier, TPA, agency, and public and private employer clients – providing Group Health, Work Injury, and CDHP administrative services.  Its sister firm, VIP Care Management, received the top national award in 2010 for its health management program.  Verity’s increasing focus in recent years has been on data exchange and technology services.

About Caprock

Caprock Health Group is a health care services organization comprised of affiliated companies working in close coordination to provide an effective integrated solution for employers and insurance brokers who want the very best in self-funded health plan management and fully insured plan access.  Caprock Health Group offers a full suite of products which are designed to provide each employer maximum cost savings.  Our focus is helping employers manage long-term health care costs by empowering employees through education, creating healthier consumers, and incorporating highly effective cost containment strategies.

Contact Information:

 Annette Alonzo

Director of Marketing

Caprock Health Group


Let The Games Begin

Friday, July 19th, 2013


Let the games begin!

On one side are ambitious third parties in healthcare reform – whose goal is to save money by taking control of healthcare decisions from doctors and patients. Using the very EHRs the doctors and patients are still paying for, mystery algorithms will churn out money-saving computerized solutions that repeatedly signal that doctors are paid too damn much.

 On the other side are doctors with practice consultants. Their goal is to maximize profits by gaming the stakeholders’ half-baked money-saving ideas which assume doctors are idiots.

 “HHS auditors target upcoding of Medicare bills via EHRs,” by Rich Daly, Modern Healthcare

Darrell Pruitt –

ObamaCare Loophole Spawn Skinny Plans

Friday, July 19th, 2013

loop“Company-backed insurance does  not have to cover the 10 categories of services in the health care law’s  essential health benefits.”


And They Lived Happily Ever After

Thursday, July 18th, 2013


Price Drives Decisions, Not Expanded PPO Networks – Narrow Networks Gaining Market Share

Thursday, July 18th, 2013

ppoSeveral insurers preparing for the health insurance exchanges opening in October are researching how consumers will choose a health plan. The answer: low costs, reported the Wall Street Journal.

Insurers have created simulated exchanges that allow consumers to test drive the experience of shopping for health coverage in an online marketplace. Simulations are demonstrating that consumers most often choose plans based on price, including the amount of subsidies available to them. They also select coverage quickly, rarely analyzing benefit details in depth.

Consulting firm Booz & Co.’s simulated exchanges have revealed that premiums were the most important aspect to health coverage, followed by cost-sharing features, such as deductibles. Meanwhile, McKinsey’s simulations have found that most consumers would rather save money than have a larger network of doctors and hospitals.

“People were willing to trade off network access for price,” Shubham Singhal, a McKinsey director who leads the firm’s healthcare practice, told the WSJ.

That was the same conclusion drawn by Blue Cross Blue Shield of Rhode Island (BCBSRI), which conducted a simulated exchange with about 500 consumers to obtain “a real-life glimpse into how people will behave,” said Jim Gallagher, BCBSRI’s vice president of marketing. The simulation showed that consumers only spent about nine minutes on the decision process, with 48 percent of consumers reporting premiums were the most important factor to their decision, and 41 percent said they would sacrifice provider choice to save money.

BCBSRI is using the results of the simulation to determine its exchange offerings. For example, it choose not to offer a platinum plan that could attract high-need members and is adding an online tool for consumers to consult with an adviser as they shop for health plans.

Simulating exchanges can also help inform insurers’ promotional campaigns like the one the Blue Cross and Blue Shield Association launched with Walgreens, which FierceHealthPayer previously reported, to better educate consumers and compel them to sign up for the exchanges.

Editor’s Note: What constitutes a narrow network? Doctors who charge more than others, or doctors that agree to take less than others? Carriers are carving out their lower cost providers and calling that network their “Premier” or “Gold” network to denote value to the consumer. Good marketing tactic.

Nearly Half Of Brokers Plan To Exit

Thursday, July 18th, 2013

  There’s no question that the nation’s health care system is in a state of change and unrest — and it looks like a good number of health insurance brokers are sick and tired of it. (more…)


Wednesday, July 17th, 2013

emptyBy William Rusteberg

Under ObamaCare as it is now written and understood, if an employer with more than 50 employees wants to avoid all punishment, the 60%/9.5% Rule controls. The former addresses “minimum actuarial value” while the later addresses  the “affordability” mandate.

Minimum value simply means the health plan offered by the employer should actuarially cover 60% of health care costs. Experts say a plan with a $2,000 deductible, 80/20 and no co-pays qualifies. Other experts say a $3,000 deductible, 60/40 qualifies.  Take your pick.

Affordability, as defined by Congress, stipulates that an employer sponsored health plan is affordable if participants pay no more than 9.5% of their gross income towards the cost of coverage.

Some employers may adopt a “100% plan reimbursement strategy” in conjunction with  these two mandates by utilizing existing government reimbursement rates, i.e. Medicare. Medicare reimbursement rates  are significantly lower than rates through PPO contracts, which typically reimburse hospitals 300% of Medicare and more.

A Plan Sponsor may decide that paying 100% of Medicare is a lot less expensive than paying 300% of Medicare.

Despite punishing ACA mandates employers still retain some degree of control over their profit and losses. The glass is half full.




Blue Cross Cuts Ties With Mississippi Hospitals

Wednesday, July 17th, 2013

JACKSON, Mississippi — Blue Cross and Blue Shield of Mississippi has told the state’s second-largest hospital owner that it will end its contract with the company’s 10 Mississippi hospitals at the end of August.

The insurer sent the notice of termination to the Health Management Associates hospitals statewide on June 25. That was a week after Florida-based HMA sued Blue Cross for $13 million, claiming the Flowood, Miss., insurer is breaking contract terms.

At the same time, Jackson’s University of Mississippi Medical Center and Blue Cross continue talks over payment rates, with the chance that the insurer will no longer contract for treatment at the state’s largest hospital.

If Blue Cross no longer has contracts, hospitals would be reimbursed at lower out-of-network rates, meaning individual patients could face much higher out-of-pocket costs.

— The Associated Press

Hospitals Sue Blue Cross Over Payments

Wednesday, July 17th, 2013

Ten Mississippi hospitals, including several in metro Jackson, claim in a breach-of-contract lawsuit that Blue Cross Blue Shield of Mississippi shortchanged them by more than $13 million in improperly reduced inpatient payments for a range of medical services.

The suit, filed Tuesday in Hinds County Chancery Court, contends Blue Cross Blue Shield reduced its inpatient payments to the hospitals, each owned by Health Management Associates, by rewording certain sections of its policy manual to reflect those changes instead of negotiating any payment adjustments with the hospitals, which HMA said the insurer is obligated to do.

Local hospitals that are plaintiffs include Jackson’s Central Mississippi Medical Center, Crossgates River Oaks Hospital in Brandon, Madison River Oaks Medical Center in Canton, and River Oaks Hospital and Woman’s Hospital, both in Flowood. The lawsuit seeks to recover the amount it says the hospitals have been underpaid.

“It’s a contractual issue between the parties. They just made changes without notifying the hospitals. They made it unilaterally,” said Tom Kirkland, an attorney for the plaintiffs.

Blue Cross Blue Shield would not comment on the allegations.

The lawsuit says Blue Cross Blue Shield and the hospitals typically enter into contracts, which are regularly renewed, that govern the services the insurers provide, including the amount of money it pays each hospital for inpatient care.

Any changes to what is paid, the suit contends, is to be agreed to “by mutual written consent” of each party, and that any changes Blue Cross Blue Shield wants to make need to be addressed with each hospital “in writing at least 30 days before the proposed changes are to become effective.”

But after an impasse in 2011 between the hospitals and Blue Cross Blue Shield over payment rate increases, the insurer inserted new language into its policy manual reflecting the payment reductions, the suit claims. The underpayments, Kirkland says, apply to the treatment of “a large number of patients,” although he couldn’t provide a specific number.

“It is unfair for insurers like Blue Cross Blue Shield to not honor the amount they agreed to pay,” said Bill Williams, HMA’s division CEO for the hospitals, said in a news release announcing the lawsuit. “That may benefit the insurance company and its executives, but it harms our hospitals and the communities we serve.”

The other hospitals involved in the lawsuit are Biloxi Regional Medical Center, Gilmore Regional Medical Center in Amory, Natchez Community Hospital, Northwest Mississippi Regional Medical Center in Clarksdale and Tri-Lakes Medical Center in Batesville.

To contact Jeff Ayres, call (601) 961-7050. He is @jeffayres71 on Twitter.

San Benito ISD On-Site Clinic Saga Continues – Oops, Your Terminated!

Wednesday, July 17th, 2013


Despite support from the board’s four-member majority, trustees voted 4-1 this week to give ISD Managed Care Services a two-month termination notice.


Empire Blue Cross & Castlight Health Introduce Reference Based Benefits

Wednesday, July 17th, 2013
NEW YORK--(BUSINESS WIRE)--July 10, 2013--

Empire BlueCross BlueShield and Castlight Health, a leader in health care transparency, is announcing a joint offering for employers called Reference Based Benefits. Innovative health care benefit designs are an important component of controlling costs while increasing access to quality care. The new offering combines Castlight’s consumer-focused health care transparency solution with Empire’s focus on customer service, broad provider networks and efficient administrative processes.


Texas Insurance Code – Chapter 541 Unfair Methods Of Competition And Unfair Or Deceptive Acts Or Practices

Saturday, July 13th, 2013


Texas TPA’s, their insurance carrier partners, insurance agents and brokers should understand that Chapter 541 of the Texas Insurance Code applies to them:

§ 541.003. UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE ACTS OR PRACTICES PROHIBITED.  A person may not engage in this state in a trade practice that is defined in this chapter as or determined under this chapter to be an unfair method of competition or an unfair or deceptive act or practice in the business of
Added by Acts 2003, 78th Leg., ch. 1274, § 2, eff. April 1, 2005.

Sec. 541.054.  BOYCOTT, COERCION, OR INTIMIDATION.  It is an unfair method of competition or an unfair or deceptive act or practice in the business of insurance to commit through concerted action or to enter into an agreement to commit an act of boycott, coercion, or intimidation that results in or tends to result in the unreasonable restraint of or a monopoly in the business of insurance.

Molly Mulebriar, investigative reporter from Warring, Texas, is currently winding up her investigative report of a Texas TPA’s efforts to boycott a competitor in violation of the Texas Insurance Code.

“We will report that a Texas TPA, in a coordinated effort with a major insurance carrier,  clearly violated Section 541.054 of the Texas Insurance Code” said Mulebriar. Mulebriar’s report will be posted on in a few days.


Union Letter: Obamacare Will ‘Destroy The Very Health and Wellbeing’ of Workers

Saturday, July 13th, 2013


“On behalf of the millions of working men and women we represent and the families they support, we can no longer stand silent in the face of elements of the Affordable Care Act that will destroy the very health and wellbeing of our members along with millions of other hardworking Americans.”


Catholic Health Association “Satisfied” With ACA Contraception Rules

Saturday, July 13th, 2013


The Catholic Health Association, one of the Obama administration’s most reliable allies in passing and promoting the health care reform law, has made peace with the contraception provision that distressed many of its members.


ACA Employer Mandates Delayed? No, Only Affects Penalties, Not Most Mandates

Friday, July 12th, 2013


“………the delay does not affect a number of provisions of ACA that are applicable to employer sponsored group health plans which are scheduled to take effect in 2014….  the delay affects only the penalties applicable to employers that fail to offer minimum value affordable coverage“mini-med” plans and stand alone health reimbursement accounts (HRAs) cannot be maintained after the 2013 plan year……


How Employers Might Use Self-insurance To Sidestep Affordable Care Act Rules

Friday, July 12th, 2013


By Jay Hancock

Self-insurance has been called an Obamacare loophole. That’s because the arrangement – in which the employer pays medical bills instead of an insurance company – is immune to taxes, benefit requirements, profit limits and other rules set by the Affordable Care Act.


To King Obama: On Bended Knee We Beg Your Excellency To Permanently Delay ObamaCare

Wednesday, July 10th, 2013


Senators are begging for the implementation of Obamacare to be permanently delayed:

“We write to express concern that in your recent decision to delay implementation of the employer mandate, you have unilaterally acted and failed to work with Congress on such a significant decision.  Further, while your action finally acknowledges some of the many burdens this law will place on job creators, we believe the rest of this law should be permanently delayed for everyone in order to avoid significant economic harm to American families,” the senators write.


New Carrier Strategy?…..To Heck With Negotiating With Hospitals & Doctors, Just Buy Them Instead!

Wednesday, July 10th, 2013
ownership“Today is a new day,” CEO William Winkenwerder said…….. It  (Highmark) shelled out about $1.6 billion to buy seven  hospitals, including the just-completed acquisition of St. Vincent Health System  in Erie, a number of doctor practices and other components……….

Minimum Value Rules On Hold For 2014?

Wednesday, July 10th, 2013

exasperated man

Here is another ObamaCare glitch:

Editor’s Note: There are so many “glitches” coming out these days, it is hard to keep up with all of them.  Many are  giving up trying to keep up. Otherwise any sane person could  become a perfect candidate for the nut house. To maintain sanity, Homer G. Farnsworth M.D.  suggests we all sit back, take everything with a grain of salt, and wait until the dust settles.

Another PPACA Glitch Surfaces………….

Wednesday, July 10th, 2013

glitchWASHINGTON (AP) — Some smokers trying to get coverage next year under the Patient Protection and Affordable Care Act (PPACA) may get a break from tobacco-use penalties that could have made their premiums unaffordable.

The Obama administration — in yet another health care overhaul delay — has quietly notified insurers that a computer system glitch will limit penalties that the law says the companies may charge smokers. A fix will take at least a year to put in place.


Envision To Be Sold To TPG

Tuesday, July 9th, 2013
Wall Street Journal   TWINSBURG, Ohio--(BUSINESS WIRE)--July 08, 2013--

Envision Pharmaceutical Holdings Inc., the parent company of Envision Pharmaceutical Services (EnvisionRxOptions), a national, full-service pharmacy benefit management (PBM) company, today announced that it has signed a definitive agreement to be acquired by TPG, one of the world’s leading private investment firms.


ObamaCare Honor System Enacted

Monday, July 8th, 2013


With the employer mandate postponed until 2015, compliance with reporting requirements are on hold. How will the government be able to verify eligibility for subsidies for applicants who are employed? Answer: ObamaCare Honor System:

San Benito ISD To Award TPA Services……………..Again.

Sunday, July 7th, 2013


San Benito ISD will meet on Tuesday to award the district’s third party administration for the employee health plan. The new “managed care” plan is to take effect October 1. According to news reports, the new plan will cost less with improved benefits, an astounding achievement. ( )


San Benito ISD To Terminate Clinic Management Company?

Saturday, July 6th, 2013

sanbenitoSAN BENITO — School board members will consider terminating the services of the district’s health clinic administrator, more than a month after the U.S. Internal Revenue Service placed a lien demanding the district pay delinquent taxes owed by the clinic.


Texas Based Restuarant Chain Reacts To ACA

Saturday, July 6th, 2013


By Molly Mulebriar

A large Texas based restaurant chain with 115 locations and 5,500 employees was in a quandary. ACA was going to cost them millions of dollars whether they complied or not.  What to do?”

They decided the best course of action was to franchise each location, giving current managers the first option to run their own operation. The corporation still controls how the business is run and operated through a detailed franchise agreement. Corporate income is derived from franchise fees and property rentals. The franchisees now bear the risk of running their own business.

Many locations have less than 50 full time employees, which allows them to avoid ACA mandates.

To date 24 locations are franchised.





Renting Medicare’s Provider Network

Friday, July 5th, 2013


PPACA – Now What?

Friday, July 5th, 2013


By William Rusteberg

With the recent decision by the Obama administration to postpone full implementation of ACA until 2015, many employers are delighted, yet confused. Will there be other surprises between now and 2015? Will the mid-term elections in 2014 have any impact?

Congress is already toying with changes. For example, there is bipartisan support brewing to change the definition of full-time employees from 30 hours to 40 hours per week. There are thoughts of increasing the employer mandate from groups of 50 or more employees to 100 or more.

Some employers, overly eager to react to ACA, have prematurely made changes to their health plans. For example, “Skinny Plans” are the rage these days with groups with low wage employees. Going from a mini-med plan to “Preventive Care Plan” with a few bells and whistles increases liability. Those employers who have implemented these plans are now stuck with them for up to two years or more. Buyer remorse must be awful. ( )

Plan Sponsors would be wise to be cautious, yet proactive. Efforts in self-funding with an eye towards saving money through avoidance of premium taxes, some state and federal mandates, and direct provider contracting should continue at full steam.


Tuesday, July 2nd, 2013
The New York Times | BREAKING NEWS ALERT | Unsubscribe
BREAKING NEWS Tuesday, July 2, 2013 6:12 PM EDT
White House Delays Employer Health Care Rule Until 2015

The Obama administration announced on Tuesday it would delay for a year, until 2015, the Affordable Care Act mandate that employers provide coverage for their workers or pay penalties, responding to business complaints and postponing the effective date beyond next year’s midterm elections.
“We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively,” Mark J. Mazur, an assistant Treasury secretary, wrote on the department’s Web site in disclosing the delay.

See additional news reports:

Administration Delays ACA Reporting and Pay-or-Play Rules for Businesses
“The Administration is announcing that it will provide an additional year before the ACA mandatory employer and insurer reporting requirements begin. This is designed to meet two goals. First, it will allow us to consider ways to simplify the new reporting requirements consistent with the law. Second, it will provide time to adapt health coverage and reporting systems while employers are moving toward making health coverage affordable and accessible for their employees. Within the next week, we will publish formal guidance describing this transition.”                         (U.S. Department of the Treasury)

Health Law Employer Mandate Delayed by U.S. Until 2015
“The move may lead some employers to delay providing coverage to workers. The law’s individual mandate remains in effect, a provision that requires most Americans to carry health insurance…. The 2010 Patient Protection and Affordable Care Act allows the Obama administration to set the starting date for the employer coverage reporting requirement that’s the linchpin of the mandate. The administration had not yet announced a date … Still, enforcement of the mandate had been widely expected to begin in 2014[.]”                         (Bloomberg)

Obama Administration to Delay Health Law Requirement Until 2015
“The Obama administration announced on Tuesday that it would delay for a year, until 2015, the Affordable Care Act mandate that employers provide coverage for their workers or pay penalties, responding to business complaints and postponing the effective date beyond next year’s midterm elections…. The change does not affect other central provisions of the law, in particular those establishing health care marketplaces in the states … where individual Americans without health insurance can shop from a menu of insurance policies. Under those provisions, subsidies are available for lower-income individuals who qualify. However, it will be difficult for officials running the exchanges to know who is entitled to subsidies if they are not able to confirm whether employers are offering insurance to their employees.”                         (The New York Times; subscription may be required)

Obamacare Employer Mandate Delayed Until After 2014 Midterms
“Delaying the requirement until 2015 is an enormous victory for businesses that had lobbied against the healthcare law. It also means that one of healthcare reform’s central requirements will be implemented after the 2014 midterm elections, when the GOP is likely to use the Affordable Care Act as a vehicle to attack vulnerable Democrats. In a White House blog post, senior adviser Valerie Jarrett wrote that the administration believed it needed to give employers ‘more time to comply with the new rules.'”                         (The Hill)

United HealthCare Contract Negotiations With Tenet Continue

Monday, July 1st, 2013

This communication is to inform you that a  letter was mailed to UnitedHealthcare members in the Houston market on June 28 regarding our ongoing negotiations with Tenet Healthcare.

Please find background on the communication below that will assist you should you be contacted by an employer group.

UnitedHealthcare in Negotiations with Tenet We are in negotiations with Tenet Healthcare Corporation (Tenet) to renew its national commercial and Medicare contracts, beginning Aug. 1, 2013. Despite several months of intense negotiations, we have not yet reached an agreement. As our discussions continue, it has become necessary to begin notification to members within 30 days of the termination date that these hospitals may no longer be participating on Aug. 1, 2013.

Fair and Reasonable Contract We are committed to continuing our discussions and reaching a mutually acceptable agreement with Tenet. Continuity and access to quality, affordable health care for members are key priorities during negotiations.

We are working hard to ensure that Tenet is reimbursed at a rate that is not only fair and reasonable, but consistent with trends in each of the local markets it operates. We demonstrate this commitment by contracting with more than 780,000 physicians and 5,900 hospitals across the country to participate in our network. Our network of hospitals in the Houston area remains strong and stable.

For more information, please contact your UnitedHealthcare representative.

See previous posting:

Editor’s Note: What is “fair and reasonable?” How about Medicare +20%? Naw, that won’t fly, will it Uncle Herrman?