ObamaRe II Low “Premium” Plan Debuts In Less Than 35 Days!


By William Rusteberg

Have you ever wondered what that $63 “Reinsurance Fee (tax)” really is and how it applies to ObamaCare? Or did you have some vague idea that the fee (tax) was a set-aside to somehow offset losses insurers may suffer through ObamaCare exchanges?

Introducing Stop Loss Insurance through ObamaRe II!

This government owned and administered reinsurance program  will reimburse insurers in the individual market for 80% after a specific stop loss deductible of $60,000 up to a cap of $250,000 for the 2014 Plan Year.

However, just this week the HHS has proposed lowering the specific stop loss deductible to $45,000 in 2014 since it is now anticipated that the “pool” of insureds is likely to be smaller than first anticipated as well as a higher risk due to adverse selection.

ObamaRe will also lower the annual “stop loss premium” in 2015 from $63 to $44. On a monthly basis, this comes in at $3.67, a very low premium for a $45,000 specific deductible.

Oh, but wait, HHS is now proposing that the specific deductible be increased to $70,000 in 2015 with a coinsurance rate of 50%, down from 80%. The $250,000 cap will remain in place.

A monthly stop loss premium rate of $3.67 for a $70,000 specific, 50/50% coinsurance with a $250,000 cap is competitive. Try finding a competitive alternative in the private  sector stop loss market.

ObamaRe I, however,  still remains the premier stop loss policy ever devised by mankind. See http://blog.riskmanagers.us/?p=12875

Editor’s Note: What does the ObamaRe “stop loss policy” consider the basis of payment? Usual & Customary, Medicare reimbursement benchmark, cost plus, reference based pricing, Medicaid benchmark, or PPO contracted pricing?


Weslaco ISD vs Aetna – News Reporter Seeks Update


Texas news reporter seeks update on Weslaco ISD vs Aetna lawsuit: http://bloximages.newyork1.vip.townnews.com/galvestondailynews.com/content/tncms/assets/v3/editorial/6/08/6080d8ce-b862-11e2-afc1-0019bb30f31a/518b28d375654.pdf.pdf

See original pleading: http://blog.riskmanagers.us/wp-content/uploads/2011/06/Weslaco-vs-Aetna.pdf

Editor’s Note: From our perspective, the most interesting information coming out of this cause of action is the Aetna ASO contract provisions regarding earned fees derived from PPO discounts. Working the spread between charge master rates and managed care negotiated allowed charges can be lucrative. For example, a 9.5% of “savings” fee can add up quick. Hospital charge masters are third party intermediaries best friends – http://blog.riskmanagers.us/?p=11527

Also see http://blog.riskmanagers.us/?p=6040, Weslaco vs Aetna


BCBS Pays 100% Medicare Allowable For Non-Network Providers


What is Blue Cross’ allowed amount for nonparticipating providers? For physicians, clinics, Ambulatory Surgery Centers (ASC) services, and/or facility services by nonparticipating providers, with some exceptions, the allowed amount for most plans is 100% of the Medicare Allowed Charge that is published at the United States website for Centers for Medicare and Medicaid Services (CMS): http://www.cms.gov/ ExternalLink .”

If Blue Cross pays 100% of Medicare allowable for non-network providers, what do they pay for network providers? Do they pay more, or less? Clue – http://blog.riskmanagers.us/?p=13247


Editor’s Note: From all indications, the BUCA’s pay out-of-network providers anywhere from 100% – 105% of Medicare allowable.

Medicare To Pay Flat Rate For Clinic Visits


Despite criticism from hospitals and doctors, the CMS intends to pay flat rates for Medicare visits to outpatient clinics instead of payments that vary with the severity of the patient’s condition. However, the agency decided not to enact a similar policy for emergency-room visits—at least for the time being.
The 1,200-page outpatient prospective payment system rule for 2014, posted the Wednesday afternoon before Thanksgiving, says the agency is changing its longstanding approach to paying for clinic visits because of a widespread concern that the old system encourages upcoding.

Continue reading Medicare To Pay Flat Rate For Clinic Visits

U.S. Delays On-line Enrollment For Small Business


WASHINGTON (Reuters) – The Obama administration on Wednesday announced a one-year delay in online health insurance enrollment for small businesses with fewer than 50 full-time workers that qualify for subsidized coverage under Obamacare.

The announcement, which comes nearly two months after the October 1 rollout of the landmark healthcare law, said employers seeking coverage through the federal Small Business Health Options Program, or SHOP, marketplace would be able to enroll off-line through insurance companies, agents and brokers.

Up to now, SHOP enrollment has been available only through paper applications.

(Reporting by David Morgan; Editing by David Brunnstrom)

Optum Urgent Care Clinics to Open in Kansas City and Houston Markets


November 19, 2013

Optum has identified markets nationwide that have high emergency room utilization and shortages of primary care physicians. With plans to open urgent care clinics nationally in 2014, locations will open in Overland Park, Kan., in December, and in the Tanglewood and Copperfield communities of Houston, Texas, in January.

Optum Clinic Urgent Care Initiative Goals:

  • To give your clients and members increased access to affordable options for employees who do not have a primary care physician, need immediate attention, or require care outside of normal office hours. On-site lab and X-rays for same-day test results will provide further savings.
  • To connect members to appropriate downstream medical services. Optum Clinic will call every patient three days post-visit to assess whether further treatment is necessary. Where appropriate referrals will be made to UnitedHealth Premium® Designated providers.
  • To reduce high cost of Emergency Room visits by educating members about additional care options.  Many people go to an ER for illnesses and injuries that can be treated at an urgent care.  The average cost for an ER visit in these markets is between $1,200 and $1,500.  We expect to be competitively priced in the marketplace, whereas the average cost of an urgent care visit at $155

Optum Clinic Offers a Wide Range of Health Care Services and Advantages:

  • Wellness visits, including biometric screenings, vaccinations, physical exams and pre-employment physicals.
  • Real-time access to doctors and advance practitioners seven days a week
    • Monday – Friday 7:30 a.m. to 8 p.m.
    • Saturday – Sunday 9 a.m. to 5 p.m.
    • Open holidays

For more information, please contact your UnitedHealthcare representive.

** Cost information represents averages only based on internal claims data and is not tied to a specific condition, level of coverage or treatment. Actual out-of-pocket costs will vary based on plan design.

Reinsurance Fee Rules Exempt Certain Self-Funded Group Health Plans

give and take

Matt Dunning

November 26, 2013 – 1:59 pm ET

Proposed rules issued this week would provide certain self-funded group health care plans with relief from the financial burden of one aspect of the health care reform law.Employers that self-insure and self-administer health coverage for their employees will be exempt from having to pay into reform law’s three-year Transitional Reinsurance Program for the 2015 and 2016 plan years, the Department of Health and Human Services said in rules proposed Monday.  Continue reading Reinsurance Fee Rules Exempt Certain Self-Funded Group Health Plans

Hospital’s Compensation Of Employed Physicians Violates Stark Law

amollyA federal court’s November 13 ruling demonstrates that a hospital’s compensation of physicians can violate the Stark Law’s prohibition against paying for Medicare referrals, even when the physicians are the hospital’s own employees and their payment pool is distributed in proportion to their personally-performed services.

The case, United States et al. v. Halifax Hospital Medical Center […]

You may view the latest post at http://beyondhealthcarereform.com/hospitals-compensation-of-employed-physicians-violates-stark-law/

This article posted by: Thomas Schroeder  – Faegre Baker Daniels


Patient Numbers Overwhelm On-Site Clinic at San Benito Independent School District


“Free” Health Care or Pent-Up Utilization, or Both?

Nov. 05–SAN BENITO — Some officials have raised concerns over the San Benito school district health clinic’s new managed care plan, which has been touted as a model of the Affordable Care Act.

Continue reading Patient Numbers Overwhelm On-Site Clinic at San Benito Independent School District

Compared To Medicare, What Does Blue Cross Pay Providers? Medicare + 130%, 216% or 129%?


Editor’s Note: Managed care contracts are closely guarded secrets. Try getting your hands on one and you will understand the difficulties involved in learning the truth behind managed care contracts. We have succeeded in obtaining copies of contracts, including the Holy Grail, a Blue Cross hospital contract, but that is another story to be told some other time. The following article provides the reader clues about what Blue Cross pays on their North Carolina providers contracts and the difficulty in obtaining pricing information from major health insurance carriers.

The Segal Company, according to this article, has determined that on average Blue Cross pays 130% of Medicare towards professional services (physicians), 216% for out-patient hospital services and 129% for in-patient hospital services.

(Be sure to read comments at end of article)

Continue reading Compared To Medicare, What Does Blue Cross Pay Providers? Medicare + 130%, 216% or 129%?

Texas Fully-Insured vs Self-Insured Enrollment Breakdown Among The BUCA’s


A December 2011 study published by HealthLeaders InterStudy Group on the Texas health insurance market is an interesting read. For example, Blue Cross, United HealthCare, Cigna and Aetna (BUCA) show that more than half of their Texas large group enrollment are on self-funded plans versus fully-insured plans.

According to this report, 55% of Blue Cross’s large group enrollment is self-funded while Cigna’s and Aetna’s are in excess of 80% followed closely by United HealthCare at 75%.

Editor’s Note: With ACA taking full effect in 2014 we expect more employers will self-fund and these numbers will increase. For a copy of the report, write RiskManager@RiskManagers.us


Better Care At Lower Cost. Is It Possible?

By Deborah Lorper

Even if you’re not an expert on health care or the Affordable Care Act, you’ve probably heard that the costs of care in the United States are high—really high. Maybe you’ve even heard that the U.S. spends more on health care than any other country. But what does it mean? Why does it happen? And can we do anything about it?

For starters, the $2.9 trillion we spend annually on health care—a whopping $9,200 per person—isn’t necessarily buying us the best care or ensuring good health. In fact, not only does the U.S. fare worse in terms of infant mortality and life expectancy than other developed nations, it also tops the list for deaths that are considered preventable with timely and appropriate treatment. What’s more, a hospital stay or common diagnostic tests, like MRIs, cost many times more in the U.S. than in countries like Germany or Japan.

These high costs place a heavy burden on government, which funds Medicare, Medicaid, and other public insurance programs; on employers, who help pay for the health coverage of workers and their families; and on American households, who feel the pain in their pocketbooks, through higher taxes and reduced wages.

GETTING AT THE ROOT OF THE PROBLEM Penny Before we learn about these new approaches to paying for health care, let’s take a closer look at where costs really pile up.

Paying for More Doesn’t Always Get Your More Many experts point to the way health care providers in the U.S. are typically paid for the services they deliver as a major culprit in driving our out-of-control costs. Under our fee-for-service system, most physicians, hospitals, and other providers receive a payment for each service, be it an office visit, lab test, or medical procedure—regardless of whether or not they help (or harm) the patient. In other words, provider payment is based on the quantity of care provided, rather than the care actually needed by the patient, or the effectiveness of the treatment.

Continue reading Better Care At Lower Cost. Is It Possible?

Retail Health Clinics

clinic12A recent study from the Center for Studying Health System Change reported that 1% of U.S. families reported using a retail health clinic in the previous year in 2007 and by 2010 that usage had increased to 3%. The Robert Wood Johnson Foundation reported that retail clinics are “projected to account for about 10 percent of outpatient primary care visits by 2015.” A recent estimate claims that more than 1,400 health clinics now operate inside retail chain stores.

Does the increased presence and use of retail clinics matter? It should.

Retail clinics rely heavily on nurse practitioners who operate without an on-premises physician. These nurse practitioners are less expensive than doctors with respect to salaries. Consequently, retail clinics can provide basic care at lower costs than would be the case at a typical primary care physician. For example, Walgreens healthcare clinic advertises prices of $79 to $89 for patient exams pertaining to illness, pain, injury & skin exams. In comparison, FairHealthConsumer.org estimates that an established patient office or other outpatient visit (typically 10 minutes) paid out-of-pocket would cost $138 in a Boston suburb. Surprisingly, the price difference between retail clinics and physician practices has not resulted in faster adoption of these facilities by the public.

However, there are objections to retail clinics in some quarters.  Dr. Sam Unterricht, president of the Medical Society of the State of New York, has stated “The society, and physicians in general, think retail clinics are a threat to the quality of care and a threat to physicians financially.” Part of the concern is the potential conflict of interests with respect to prescribing drugs dispensed at the pharmacy hosting the retail clinic or recommending other medical supplies sold at the pharmacy. However, conflicts of interest also exist for doctors who could direct patients to doctors and medical services offered by the physician’s practice. It would seem to me that the quality of clinical outcomes is more important in this discussion, though not to the exclusion of exploring potential conflicts of interests.

The clinics themselves are expanding the services they offer, from routine vaccinations to the treatment and management of chronic conditions such as asthma, diabetes, and hypertension. I have not seen any negative press regarding the quality of vaccination work, blood pressure checks, and other basic care provided at retail clinics. If that trend is maintained for expanded medical services such as the management of chronic conditions, retail clinics could be one small step toward curbing healthcare costs in the U.S

By Kev Coleman   www.healthpocket.com

Obama Administration, Insurers Oppose Hospitals Purchasing Insurance For Sick, Poor


The Obama administration and insurers oppose a proposal that hospitals buy their sickest and poorest patients health insurance under the Affordable Care Act, in fear it would create even more difficulties in the new healthcare exchange, the Financial Times reported.

Continue reading Obama Administration, Insurers Oppose Hospitals Purchasing Insurance For Sick, Poor

Reference Based Pricing Gaining Attention


Many employers have begun to adopt a strategy known as “reference pricing” to help reduce health care costs. Under this benefit design, employees get insurance plans that set price caps on certain services and procedures. Enrollees are allowed to use any provider. But if they use providers with fees higher than the “reference price,” they must pay the difference between the reference price limit, determined by the employer or insurer, and the actual charge.


Continue reading Reference Based Pricing Gaining Attention

HSTechnology Inc. Provides Cost Plus – Reference Based Pricing Model Since 2009


“HST realizes that not all highly inflated claims will result in a fair and reasonable payment arrangement with the provider. Egregious claims reviewed by HST that are not mutually resolved can be directed to our network of law firms. We also have a Patient Advocacy Center (PAC) that provides a coordinated and collaborative roll between the payer, provider and member. HST ‘s expertise on the pricing and reimbursement cost is included at no additional fee. Supporting policy language significantly improves the results based on objective industry metrics.”     www.hstechnology.com

Continue reading HSTechnology Inc. Provides Cost Plus – Reference Based Pricing Model Since 2009

Blue Cross Executive – Urgent Care Centers Don’t Pay Off

urgentcare   By Alicia Caramenico

Insurers have turned to urgent care centers to curb costs by diverting patients with minor problems from the emergency room, but it remains to be seen whether the centers actually save money, The Buffalo News reported.

“The centers have not yet been successful at controlling health costs, and they have pulled volume away from primary care doctors,” Raghu Ram, M.D., vice president and chief medical officer at BlueCross BlueShield of Western New York told the Buffalo News.

Blue Cross Blue Shield of North Carolina also has banked on urgent care clinics to help it defray the cost of hospital ER visits, noting that if just 5 percent of non-emergency patients sought treatment at urgent care centers instead of emergency rooms, medical spending could drop by $8 million a year, FierceHealthPayer previously reported.

But despite intentions to reduce costly ER use, BCBS of Western New York saw urgent care visits increase 135 percent from 2010 to 2012 among its members, while ER visits also rose 18 percent.

However, at Univera Healthcare, the Buffalo-area arm of Excellus Blue Cross Blue Shield, ER visits dropped 3 percent for the year ending in March. Physician office visits increased 3.7 percent and urgent care visits increased 27.3 percent.

As urgent care centers quickly emerge as a popular, cost-effective alternative to the ER, insurers are partnering with specific centers, the article noted, but not without conflict. For example, as of this month BlueCross BlueShield omits Immediate Care a participating provider after the urgent care organization company rebuffed its reimbursement rates.

Insurers also have problems with urgent care centers attracting patients with conditions that primary care physicians could treat at a lower cost.

“An urgent care infrastructure–with X-ray, CT scans and labs–has been built to treat higher-level conditions–things like lacerations and minor fractures,” Blues’ Ram told the newspaper. “Yet centers tend to treat a lot of low-intensity medical problems that should go to doctors. That has to change if we’re going to get value out of the centers,” he explained.

For more: – here’s the Buffalo News article

Want To Know Why ObamaCare’s Meaningful Use Requirements For Dentists Will Never Happen

meaningfuluseBy Darrell Pruitt, DDS

“As you might have recently read, Medicaid, along with Obamacare has fallen out of favor with many dentists across the nation due to Maine’s revenue-driven, ACA-style audits of its MaineCare dentists (Medicaid). Some clinics face more than $200,000 in penalties under a new audit system that threatens to wipe out services for kids.”

Continue reading Want To Know Why ObamaCare’s Meaningful Use Requirements For Dentists Will Never Happen

The Disruptive Innovation Of Price Transparency In Health Care


By Uwe Reinhardt

Until very recently, health care in the United States was delivered behind the secure walls of a fortress that kept information on the prices charged for health care and the quality of that care opaque from public view.

Over time, enormous and ever-increasing amounts of money have disappeared behind the fortress walls. Much good undoubtedly was done for patients entering the castle in search of succor. But it has been nearly impossible for prospective patients thinking of entering the health care system to know what they or someone else will have to give up in return for whatever care they will receive from the inhabitants of the fortress.     http://jama.jamanetwork.com/article.aspx?articleid=1769895

Editor’s Note: This article is eerily similar to the one found here:  http://costplusinsurance.com/articles/Managed%20Care%20Under%20Siege.pdf

Texas Independent School District – Voluntary Products – “Buy From Me, My Commissions Are Lower!”


By Molly Mulebriar

Would an insurance agent who promises to give up commissions on certain voluntary products along with an offer to provide “free” administration services in regards to a Cafeteria Plan (in return for commissions to be earned selling cancer policies and “other voluntary benefits”) be in violation of the Texas Insurance Code – rebating?

A Texas school district seeking competitive proposals for cafeteria plan administration and voluntary products recently held a public board meeting to consider awarding contracts for cafeteria plan administration and voluntary products.

One vendor, seeking the contract, made  a presentation that went something like this: ” I know it sounds too good to be true…………..we have over 400 Texas school districts as clients …………….we are officially endorsed by a statewide school association……….we will save you a ton of money on commissions…………we have more market clout because of our size………all you have to do to join is to sign an interlocal agreement……….our cafeteria plan administration is “free”………”

Is this offer a form of rebating?

“The Insurance Code §541.056 applies to life insurance, accident and health insurance, and annuities, and prohibits, among other things, an insurer, insurance agent or other regulated entity from offering an insured or prospective insured an inducement or valuable consideration not specified in the insurance policy.  It also specifically references §541.058, which enumerates certain practices legislatively declared not to constitute a rebate or inducement, and was amended by the 80th Legislature.”

Continue reading Texas Independent School District – Voluntary Products – “Buy From Me, My Commissions Are Lower!”

Veterens Day 2014

 Lt. Col. Rusteberg, May 1944, London

West Point 1934

Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.

The President of the United States of America, authorized by Act of Congress July 9, 1918, takes pleasure in presenting the Silver Star to Lieutenant Colonel (Infantry) Edwin Rusteberg (ASN: 0-19542), United States Army, for gallantry in action while serving with Headquarters, 1st Battalion, 242d Infantry Regiment, 42d Infantry Division, in action on 9 January 1945 at Hatten, France. As Commanding Officer of the First Battalion, 242d Infantry Regiment, during the action at Hatten, France, Colonel Rusteberg planned and executed the defense of that area with outstanding success. In spite of point blank fire from enemy tanks supported by Infantry that raked his positions with fire, Colonel Rusteberg by personal example held his troops in position and withstood the enemy attack. Fighting side by side with his men in the face of overwhelming odds without mechanized or artillery support, Colonel Rusteberg by his courageous leadership, tenacity and devotion to duty played a major role in the successful defense of the town of Hatten.

General Orders: Headquarters, 42d Infantry Division, General Orders No. 131 (1945)

Action Date: 9-Jan-45 Service: Army Rank: Lieutenant Colonel Company: Headquarters Battalion: 1st Battalion Regiment: 242d Infantry Regiment Division: 42d Infantry Division

Editor’s Note: The Hero at the Battle of Hatten was Vito Bertoldo. I tracked down his son who lives in California. His son served two tours in Vietnam as a Marine. He is a retired California State Highway patrolman.

Col. Rusteberg,  years after his retirment from the Army, related a story about Vito. On the voyage across the Atlantic to North Africa, word came up from the ranks that one of the cooks, Vito  Bertoldo, wanted to become a rifleman. Seems he was not getting along with his fellow cooks and wanted a transfer. Request granted. Little did Vito’s superiors know that Vito would go on to win the Congressional Medal of Honor during the Battle of the Bulge.

http://en.wikipedia.org/wiki/Vito_R._Bertoldo               http://www.youtube.com/watch?v=kLFeKn3MQE0


A German NCO who was captured praised the soldiers for their gallant stand: “We were amazed at the way your men fought. We always considered you could defeat us only if you had a tremendous amount of tanks and armor. We believed that if we met you on equal terms we would have no difficulty. At Hatten we had the armor and the artillery and the experienced men. Your men were inexperienced and lacked tanks and artillery support. Our officers said it was the best infantry defense they ever saw.”

One interesting comment is by a very experienced German officer, Col. Hans Von Luck, who fought with the German army on every front from Poland in 1939 to the Russian victory over the Germans in 1945. Von Luck commanded one of the tank units attacking Hatten and the nearby village of Rittershofen. In a book describing his World War II experiences he writes: “In those two villages, Hatten and Rittershofen, there now developed one of the hardest and most costly battles that ever raged on the Western front.”  http://en.wikipedia.org/wiki/Hans_von_Luck

Response To Milliman Cost Plus / PPO Study Indicates Cost Plus Insurance Gaining National Attention

yesnoDoes Cost Plus Make Sense?

The Milliman post (http://blog.riskmanagers.us/?p=12968) has attracted interest and inquiries from stakeholders in the health care delivery system from Arizona, Ohio, Indiana, Illinois, California, Texas and New York in recent days. We have received numerous requests for copies of the Milliman report on Cost Plus Insurance / PPO – Comparative Analysis, from national brokerage firms, stop loss carriers, several of the BUCA’s, independent brokers/consultants, third party administrators and two national hospital chains.

Why so much interest in Cost Plus Insurance? Could it be that Cost Plus Insurance and related payment platforms like Reference Based Pricing,  is rapidly gaining market share through an increasingly  competitive market?

Below are several comments we received from readers who requested copies:

Insurance Consultant: “I’d be interested in Cost Plus vs. PPO and Milliman…..every study I’ve ever seen from them makes me call them Shilliman….as in shilling for the Blues. I’ve had several claims repriced vs. Blues and cost plus beats them soundly, even after fees.  Some carriers are giving as much as 30% off of specific rates for cost plus”.

Insurance Brokerage Firm: ”Good afternoon, We are a employee brokerage firm in Ohio and we work with Milliman with our clients. We are up against another broker with one of our clients who is presenting cost plus claiming it will save money over Anthem BC/BS discounts which is very hard to believe! I would be grateful if you could share the Milliman analysis with us! I have had this client over 15 years and do not want them to make a bad decision! ”

BUCA Representative: “Very interesting. This proves my point! Besides, we have significantly better PPO discounts than Cigna”

Houston Employer: “I have been reading your blog and saw your post on RIMS. I would be interested in meeting with you to discuss our employee benefits program.”

Editor’s Note: Cost Plus Insurance, Reference Based Pricing makes sense for some, but not all plan sponsors. With more than five years experience in cost plus insurance and the learning curve associated with this new strategy in containing health care costs, we have found that Cost Plus Insurance can produce significant savings for committed plan sponsors. The key is working with partners who share the same philosophies and can readily adapt to market forces ( http://blog.riskmanagers.us/?p=12694) Working with medical care givers on a direct basis has proven to be an important part of the scheme (http://blog.riskmanagers.us/?p=1.1943)

The Milliman Report highlights two aspects of Cost Plus Insurance to which  cost plus proponents must find solutions  in order to succeed  in the market: (1). High fees charged by some TPA’s / Audit firms and (2). Competitive stop loss cover.

www.CostPlusInsurance.com provides valuable information for plan sponsors who are considering this approach to controlling health care costs.

For a copy of the Millman report, write to RiskManager@RiskManagers.us


Sutter Health Hospitals Agree To Pay $46 Million To Avoid Airing Secrets?


According to Mike Dendy, CEO/President, Advanced Medical Pricing Solutions, “This lawsuit was brought by Dr. Bert Forman as a whistle-blower action, but once Insurance Commissioner Dave Jones reviewed the case, he immediately realized how important it was and the State of California exercised its right to intervene and join the suit. In my opinion, the hospitals and Multiplan/PHCS settled to avoid all of the other things that would have been revealed if they went to court, because this case was focused on charges under just a couple of anesthesia billing codes, and it would be truly naïve to think that the hospitals’ overcharges were limited to a handful of items and aren’t happening on plenty of the other 150,000+ items on the chargemaster that haven’t been scrutinized yet.

Rick Hirsch, CEO/Chief Legal Officer, Claims Delegate Services, agrees with Dendy, but added I believe the hospitals and networks were more worried about the likelihood of the court granting Commissioner Jones’ request for a ruling from the court that PPO contract language that prohibits billing review is unenforceable because it violates existing laws and public policy. If you think about it, $46MM is a drop in the ocean compared to what hospitals and networks will lose when they are finally forced to let health plans examine their bills for errors and overcharges. And of course, they also knew that the precedent of losing the case would open the floodgates to self-funded health plan class action lawsuits.”

Continue reading Sutter Health Hospitals Agree To Pay $46 Million To Avoid Airing Secrets?

Hospital Pricing Scam Exposed – Are Health Insurance Companies Complicit – 50% Discount Off Double The Price?

scam“When the dance between hospitals and health insurers began, if a hospital’s actual cost plus reasonable profit totaled $1,000 for a given procedure and the insurer demanded a 50 percent discount, the hospitals simply negotiated towards doubling the price from $1,000 to $2,000 in order to make it all work out……”

“….today’s news is hardly going to come as a surprise to the private health insurance companies who have been complicit in this charade for so many years. Do we not have to ask why these companies would have allowed this insanity to happen? Certainly, the private insurers have more than adequate leverage in their negotiations as no hospital could hope to survive without negotiated agreements with the largest health insurance companies………………………”

Join the 50% Club – http://blog.riskmanagers.us/?p=7253  Why Some Patients Are Livid – http://blog.riskmanagers.us/?p=8541

Continue reading Hospital Pricing Scam Exposed – Are Health Insurance Companies Complicit – 50% Discount Off Double The Price?

Insurers Should Reject 3rd Party Premium Payments, HHS Says

The U.S. Department of Health & Human Services is discouraging hospitals and other health systems from providing patients with premium payment and cost-sharing support for plans purchased under healthcare reform.

In a question-and-answer document, HHS said it has “significant concerns” with hospitals supporting premium payment and cost-sharing obligations because it “could skew the insurance risk pool and create an unlevel field in the Marketplace.”

That’s why HHS is encouraging insurers to reject these third-party payments. The agency added it will monitor this practice and take appropriate action, if necessary.

Although HHS said last week that the federal anti-kickback statute doesn’t prevent hospitals and other health systems from subsidizing premiums for patients who buy insurance coverage on exchanges, the recent Q&A doesn’t contradict that clarification, AHA News Now reported.

“While the latest guidance creates many unanswered questions, its message is extremely disappointing and entirely inconsistent with the goals of expanding access to care and coverage,” Rick Pollack, the American Hospital Association’s executive vice president, said.

Discussion on Cost Plus Claims Reimbursement Programs

Tim Johnson

There is a growing interest in our industry around reducing / negotiating Provider Billed Claims based on some percentage of Medicare, Cost to Charge Ratios, Percentile of U&C or a combination of them. I have thorourghly examined all aspects of this model and have my own thoughts, but would like to hear how the industry is either accepting or rejecting these concepts and why. I will restrain from expressing my opinion until I have seen others comment one way or the other. But I would like to get an idea from others on what they feel the growth of this niche will be, where and when it can or should be used etc…

Editor’s Note: We received this from one of our readers: Most of these guys miss the point.  An employer can pay what their plan design designates they pay.  The employee can be protected as a part of the plan in the great majority of cases.  When the employee can’t be protected it is unlikely that they will have the money to make additional payments anyway and if they manage the process correctly can basically stall collections processes indefinitely.   Hospitals are political lighting rods and have to be really careful whom they chase and how aggressively they chase as scrutiny is not on their side. 

Continue reading Discussion on Cost Plus Claims Reimbursement Programs

Health Care Costs Set To Soar

By Tomas Philipson

Nations around the globe are grappling with rising costs of health care. In the US, health care liabilities and the federal debt are on a trajectory that is difficult to sustain. As the figure below shows, the Congressional Budget Offices estimates that federal deficits under current law will continue to rise faster than tax revenue, mainly driven by health care liabilities.

So why is health care spending growing? The answer is simple: Providers charge more and we continue to blindly pay through secretive managed care contracts that contain annual escalator clauses, silly outliers based on outrageous charge master rates that no one ever pays, and  consumers who don’t care about health care costs because “insurance pays it all!”

Employing reference based pricing (www.ReferenceBasedPricing.us ), or variations such as Cost Plus Insurance (www.CostPlusInsurance.com ) or Medicare Benchmarking (www.valuebasedpricing.us ), health care costs can be reduced, not increased.

Continue reading Health Care Costs Set To Soar

40% Of Unisured In Mo. Qualify For “Free” Health Insurance

Elisabeth and Mark Horst, artists in Albuquerque who earn $24,000 a year between them, qualified for a zero-premium plan.

“The availability of the zero-premium plans varies across the country. McKinsey found that about 40 percent of the uninsured in Missouri will be able to select a no-cost bronze plan…”

Continue reading 40% Of Unisured In Mo. Qualify For “Free” Health Insurance

HHS Website Fixed – Exchange Open For Business


The Obama administration announced today that the government health care exchange website has been fixed and is open for business. “Programmers, imported from Moscow, have successfully fixed the site”, said Ed Snowden, senior web analyst for Grotney Mosovich, a leading Russian web design firm. It is expected that 43 million new policies will be issued in the next several weeks through new and improved access to the site. Estimated on-line time to complete an application is 22 minutes.

Check out the website for the exchanges HERE

Snowden Reveals Source – Amazing Data Base For Insurance Agents


By Molly Mulebriar

Ed Snowden came by the house last night in a surprise visit. I am happy to report that this American patriot is still at it. He is disguised as a community organizer and blends in well, particularly in Austin. While reminiscing about our stint together in Hawaii last year, Ed said “I’ve got a good source for you, it’s free and it’s legal!”

“Government 5500 filings”, he whispered, “belong in the public domain and is readily available by going to www.freeerisa.com . Prospecting for insurance clients has never been easier. From the confines of your home, while sipping on a Margarita or Bloody Mary (depending on time of day), one can peruse through the site and retrieve valuable intelligence on targeted prospects!”

Take for instance South Texas Blood & Tissue, a 632 life case in San Antonio, Texas. We checked  www.freeerisa.comm  this morning to look up February 1 renewals in the San Antonio area. The 5500 filing was for 2012.

According to FreeErisa, South Texas Blood & Tissue has a February 1 anniversary date. Their medical plan is administered by Aetna. As “contract administrator”, the report shows Aetna’s fees to be $183,599. The Broker of Record is Gallagher Benefit Services whose commissions/fees are stated in the filing, including  commissions of $6,904 for “new business bonus.” South Texas Blood & Tissue also uses Provident Life, Colonial, 1st Colony Life and Metropolitan Life Insurance Company for various insurance cover (supplemental benefits, long term disability, life insurance) through multiple agents/brokers.

The agent listing for Colonial is interesting. There are 28 agents receiving commissions on this group through Colonial.

So there you have it. This could be a good prospect and the timing is just right. (Don’t tell anyone please, the less competition the better).