Archive for May, 2014

Association of Indiana Counties Endorses Cost Plus Insurance

Saturday, May 31st, 2014


The Association of Indiana Counties in conjunction with Apex Benefits Group has rolled out a new program to help Indiana counties reduce their health insurance costs. The new program, called Cost Plus, is an aggressive plan that reimburses health care facilities a reasonable cost but ensures the consumer reimburses an amount related to actual cost of the service.


Drudge Headlines Today Confirm Republicans Are Just Slower Than Democrats

Friday, May 30th, 2014

Why Republicans are slowly embracing marijuana – Los Angeles Times………………….GOP candidates show signs of retreat on full Obamacare repeal as midterms approach – Washington Times

drudge“The only difference between Republicans and Democrats is that Republicans just take longer to get there. Look at Medicare passage in 1966. Few Republicans voted for it. Said it was socialized medicine. Now you can’t find one Republican in office today that is against Medicare” – Molly Mulebriar

Hospital Agrees To Pay $40 Million To Settle Fraud Charges

Friday, May 30th, 2014


Editor’s Note: This article reinforces the need to audit hospital bills. If your group is with a PPO, you are either prevented from auditing claims you are funding, or you have limited audit rights. It makes perfect business sense to audit your telephone bill, credit card bill, and all other bills. So why do plan sponsors give up their audit rights under a PPO plan? That makes no sense at all.


Battle Over Drug Costs Ratchets Up – Are Price Controls Coming?

Friday, May 30th, 2014

solvadiThe battle over the rising costs of drugs, fueled by Gilead’s Hepatitis C drug Sovaldi that costs $84,000 for a 12 week treatment regimen, intensified this week. Critics of the cost have taken to referring to the drug as the “1,000-a-day” pill.


When Affordable and Un-Affordable Have The Same Meaning

Thursday, May 29th, 2014


By Molly Mulebriar

Executives at Webster’s are divided these days.  Not since “gay” went from happy to queer has the American language undergone such swift and rapid change.


San Antonio Attorneys Win Millions Against German Pharmaceutical Giant

Thursday, May 29th, 2014

boehringerGerman pharmaceutical giant Boehringer Ingelheim Pharmaceuticals Inc. has agreed to pay $650 million to settle the claims of approximately 4,000 people who were allegedly injured by use of the drug Pradaxa. San Antonio-based trial lawyer Mikal Watts, of the law firm Watts Guerra LLP, served as a co-lead counsel in the lawsuit.


Appellate Court Upholds $5 Million Award For TPA’s Concealment of PPO Access Fees

Wednesday, May 28th, 2014

mulebriarThe Sixth Circuit has affirmed an award of over $5 million to a self-insured health plan against the plan’s TPA, due to the TPA’s retention of undisclosed fees disguised as amounts payable for benefits. The plan sponsor sued after learning that it had been paying claims that included “network access” and other fees imposed by the TPA but not delineated in the administrative services agreement or Form 5500 information prepared by the TPA. After the trial court found the TPA liable for self-dealing under ERISA’s prohibited transaction rules (see our article) and for breach of fiduciary duty (see our article), the TPA appealed.

[Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of Michigan,  2014 WL 1910554  (6th Cir. 2014)]


IRS Bars Employers From Dumping Workers Into Health Exchanges

Tuesday, May 27th, 2014
“The ruling this month, by the Internal Revenue Service, blocks any wholesale move by employers to dump employees into the exchanges.”

Memorial Day 2014

Thursday, May 22nd, 2014


Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.


Employers Health Insurance Exchange

Thursday, May 22nd, 2014

Utilizing Cost Plus Insurance / Reference Based Pricing model, in partnership with a select group of medical caregivers, plan participants can achieve significant savings.  For more information contact

Why Not Just Eliminate the Employer Mandate?

Thursday, May 22nd, 2014


“The authors assert that the vast majority of employers would continue to provide benefits without the mandate, in part because of the tax break Washington provides for them.”


Obama Administration Quietly Subsidizes Rate Increases? – Mid Term Elections A Factor?

Thursday, May 22nd, 2014
The Obama administration has quietly adjusted key provisions of its signature healthcare law to potentially make billions of additional taxpayer dollars available to the insurance industry if companies providing coverage through the Affordable Care Act lose money.

Vito Bertoldo – Memorial Day

Wednesday, May 21st, 2014


Vito R. Bertoldo World War II Congressional Medal of Honor Recipient.


Study Reveals Astonishing Phenomenon: Low Rates = More Market Share

Wednesday, May 21st, 2014


BY  | MAY 21, 2014

Consumers looking for a good deal on the exchanges are more likely to pick a plan from Coventry, Humana and WellPoint.That’s according to Avalere Health, who, in new analysis released Wednesday, concluded that carriers offering low-premiums should gain 2014 market share through the exchanges.

Big Brother Is Seeking Direct Access To Your Medical Records – National Security At Stake!

Wednesday, May 21st, 2014



Did George Orwell Predict PPACA?

The federal government is piecing together a sweeping national “biosurveillance” system that will give bureaucrats near real-time access to Americans’ private medical information in the name of national security, according to Twila Brase, a public health nurse and co-founder of the Citizens Council for Health Freedom.

Editor’s Note: American voters freely gave up their liberty with the passage of PPACA. Government now controls another 1/6th of the economy. Unelected bureaucrats make up the rules leaving citizens with no recourse other than to “go along to get along” or face government sanctioned punishment including prison.


Hospitals Losing War on Transparency

Tuesday, May 20th, 2014


Wars often take years to play out, and assessing their historical impact can take decades. One of the most important factors is determining a turning point. In World War II, it was the battle of Stalingrad. In the Civil War, it was Gettysburg.Providers in general and hospitals in particular are losing so many battles in the war on price transparency so swiftly that really, the only thing left to determine  is whether they represent a turning point or just a swifter acceleration toward the inevitable.

The most recent one was the Obama administration’s decision to okay the use of reference pricing. That means if payers want to affix a payment limit on a certain procedure, such as a hip replacement, they can do so as long as it doesn’t restrain patient access to care. Expect insurers to start doing so with all deliberate speed.

>> Read the full commentary 

PPACA Plan Holders Can’t Go Back

Tuesday, May 20th, 2014


Individuals and small groups that now have PPACA coverage can’t flee back to transitional coverage.


Free At Last

Monday, May 19th, 2014


By Molly Mulebriar

Years ago, when working for a national health insurance carrier, I was asked to sign a non-compete agreement.This was after I worked there for a number of years. I refused.

My line of reasoning went something like this: “I really don’t work for you, I am simply selling my skills and time in return for money. I am independent. Why would I sign an agreement giving up my right to sell my services to anyone else for 2 years after I fire you?”

Of course, this did not sit too well with management. But, they decided I was too valuable to let go, so they quietly shelved the demand somewhere deep within HR-ville.

Now we understand that one of our dearest friends and business partners has just completed a two year non-compete period. Will it make a difference to the prior employer’s bottom line?

Free at last, free at last, what a good feeling, free at last!

Editor’s Note: Mildred now runs a TPA and does not believe in non-compete contracts. Her employees are free and independent. Enslavement is not a company sponsored philosophy.



Converting Your Group Plans To Individual Plans

Monday, May 19th, 2014


From Group to Individual

The third of four trainings in our “Road to Group Insurance Success: Understanding the Employer-Sponsored Group Market” series, From Group to Individual, will discuss how to effectively convert group plans to individual plans using the powerful tools available to GoHealth VMO agents.

Editor’s Note: With PPACA, we are witnessing a new paradigm: individual health insurance is better than group health insurance. Individual health insurance is guarantee issue (no one is turned down or singled out for lasers), is portable (not tied to employment) with many plan options to choose from. Group medical insurance is not guarantee issue for groups of 50 or more, and plan participants can be singled out due to their health conditions and placed with lasers. Now we are beginning to see a movement from group health plans to individual plans through private heath insurance exchanges which are cropping up all over the country. 

Employers are beginning to think that paying a $166 monthly tax on each of their employees in 2015  is much better than insuring them for $350 or more  each month.  Just think, no more dealing with pesky insurance brokers and consultants, no more spending months finalizing renewals, and no more nightmares about greedy health insurance companies eroding your ever decreasing profit margins. If the employer mandate is eliminated altogether (which is the talk among pundits in Washington these days), group health plans will go away quickly. 


Government Sets Complicated Fixed Indemnity Rules

Monday, May 19th, 2014


Government interference in heath care continues unabated. Citizens continue to lose freedom of choice. – “Insurers may have a chance to sell fixed indemnity health insurance to workers who get weak “minimum essential coverage” (MEC) from self-funded employee health plans.”


Rip Van Winkle – Waking Up 4 Years Later

Friday, May 16th, 2014


Have you been asleep for a while, like Rip Van Winkle, and just waking up to learn about health care reform? Or just not been interested in watching the minutiae of health care reform?  Or have you just become responsible for health care reform compliance?  We have plenty of posts about what you need to knowthe top five things, etc.  There have been political debatesjudicial battles and more, but what is the status of health care reform today?  Well, there is this notice and that notice, but you might want a higher level summary.


Reference Based Pricing Model Gains Federal Approval

Thursday, May 15th, 2014
New Health Cost Controls Get Go-Ahead From Feds – Stressed Plan Sponsors Celebrate
The Obama administration has given the go-ahead for insurers and employers to use a new cost-control strategy that puts a hard dollar limit on what health plans pay for some expensive procedures, such as knee and hip replacements.

Health Care Reform Drives Replacement of PPO’s

Wednesday, May 14th, 2014

funeral PPO’s – RIP

“When J.C. Penney Co. replaced its preferred provider organization health plan with a high-deductible health plan for all benefits-eligible employees in 2010, it was one of the few large employers to make what is known as a “full replacement” of its health plan.”


Why Some Americans Prefer Mexican Healthcare

Monday, May 12th, 2014
“And then you get a story coming out of California of people crossing the border to get quality health care. Sadly, the people it’s people leaving the U.S. to get care in Mexico. You see, health care reform in California is working SO well, no one can get a doctor’s appointment. Instead of waiting for who knows how long to see a medical professional, Americans are finding it easier to take a day trip south of the border to see someone there.


Defined Contribution Plans & Private Exchanges – Know Before You Go

Monday, May 12th, 2014


Defined contribution concepts have been migrating to the world of health and welfare benefits for a number of years. The advent of the “private exchange” and related press coverage has accelerated the public conversation about defined contribution health benefits, as the private exchange is being touted as a new way to reduce the increasing cost of health insurance. A private exchange is an online benefits marketplace where individuals purchase insurance products, including health, dental, vision, and life insurance, along with other ancillary coverage.


National Association of Purchasing Managers – Summer Session 2014

Sunday, May 11th, 2014


SUMMER SESSION 2014: A Public Purchasing Seminar

Designed for Public Purchasing Professionals with special emphasis on the latest developments that are essential in general purchasing.

Summer Session 2014 Goes Green!  Click here for details

June 25th, 26th, 27th, 2014

Hilton Garden Inn
7010 Padre Blvd.
South Padre Island, Texas 78597
Local Phone #: 956-761-8700

Employers Eye Moving Sickest Workers To Insurance Exchanges

Saturday, May 10th, 2014

Can corporations shift workers with high medical costs from the company health plan into online insurance exchanges created by the Affordable Care Act? Some employers are considering it, say benefits consultants.

“It’s all over the marketplace,” said Todd Yates, a managing partner at Hill, Chesson & Woody, a North Carolina benefits consulting firm. “Employers are inquiring about it and brokers and consultants are advocating for it.”

Editor’s Note: This is the ultimate pooling of risk strategy – pool high risk individuals to the public at large


Could This Be the Napster of the Health-Care Industry?

Friday, May 9th, 2014


“…..we have seen the future. In Boca Raton. At the mall…..We’re talking about the future of health care. It’s already the nation’s biggest and fastest-growing industry. And it’s ripe for disruption. A big fat plum, waiting for a worm.”


24 Most Creative People In Insurance Today

Friday, May 9th, 2014


“Don’t bother doing something unless your radically different from the competition” – Richard Branson


Insurance is an industry that depends upon data to accurately assess and manage risk. It is inherently a cautious business — and slow to change, many would add. But it is also a business designed to problem-solve, to engineer, to market and sell customized solutions to a consumer base that needs its products more than ever. At a moment of enormous opportunity, this industry is poised to deliver the innovative products the public is demanding. While they’re at it, thought leaders areembracing new technologies and distribution models that make buying insurance not only necessary, but also easy.

In the midst of what is arguably the most creative era insurance has seen, we present 24 innovators who are leading the charge in product development, underwriting, marketing strategy, research, and sales distribution.

Next »Page 1 of 25

Blue Cross Earns “Big Dog” Award – Dominates Exchanges

Thursday, May 8th, 2014

big dog

Since Blue Cross Blue Shield plans successfully enrolled hundreds of thousands of new consumers through the health insurance exchanges, other insurers should consider emulating what Blue Cross did during the first enrollment period.


High Deductible Gap Plan For $33.75 PEPM

Thursday, May 8th, 2014

gap plan

High Ded. GAP Plan – Guarantee issue, no pre-existing condition limitations

Children’s Hospital of San Antonio Forming Alliance With CentroMed – Medical Home For Children

Thursday, May 8th, 2014


W. Scott Bailey – San Antonio Business Journal

Christus Santa Rosa Health System’s Children’s Hospital of San Antonio has reached an agreement to work with CentroMed to improve the delivery of pediatric care in the region.

CentroMed operates 21 primary care clinics in San Antonio, providing access to care for the area’s under-served populations. As part of the collaboration, Children’s Hospital of San Antonio will provide resources to help CentroMed acquire six new pediatricians, which will expand the organization’s ability to provide primary care for some of the Alamo City’s smallest patients.

“Our mission in building San Antonio’s first stand-alone children’s hospital is to connect and develop those relationships that make it easy for parents to provide the medical care their children need,” says Christus Santa Rosa Health System President and CEO Pat Carrier. “From primary care, specialist care, urgent care and hospital care, we are aligning the best minds and hearts in pediatric medicine.”

The new collaborative agreement comes as the American Academy of Pediatrics is recommending that children should have a medical home, with physicians who know them and can coordinate their care.

“The Children’s Hospital of San Antonio’s mission aligns with ours — that all kids come first, regardless of their ability to pay,” says CentroMed President and CEO Ernesto Gomez.

“To give our kids the best, we must work together,” he adds. “The Children’s Hospital of San Antonio’s focus on providing a health care home for kids, along with their open-care model, where academic, primary care pediatricians and specialists work together, makes the process easy. It escalates the medical care for our kids in a way never done before.”

Vendor Burns Bridge In San Benito, Texas

Wednesday, May 7th, 2014


“I’m not lying,” McCall said. “I know (Garza’s) upset, but I’m just doing my job.”……..Garza retorted, “I know for a fact that is a flat-out lie………..’


Small Employers Slow To Adopt Self-Funding

Wednesday, May 7th, 2014

snooZe “I just don’t understand….”

“So far, talk among smaller employers about self-insurance has mainly been just that. And there seems to be a bit of confusion among some small businesses regarding whether they are self-insured or not. ”


1,700 Page Rule Recommends Hospital Pricing Transparency

Tuesday, May 6th, 2014


“We believe that providing charge data comparisons is introducing both transparency and accountability to hospital pricing, and we are continuing to pursue opportunities to report on hospital charging practices,” CMS said in its nearly 1,700-page rule.

“1,700 pages? What else is in there?” – Homer G. Farnsworth, M.D.


San Benito Independent School District Seeks On-Site Clinic Proposals

Monday, May 5th, 2014

otra vez

REQUEST FOR COMPETITIVE SEALED PROPOSALS – RFCSP-0514-OPCHC  –  FOR:   On-Site Primary Care Health Clinic –  PROPOSAL DEADLINE:  Thursday, May 22, 2014 @ 2:00pm


Medical Care Consultants

Monday, May 5th, 2014


Medical Care Consultants, Inc. (MCC) provides turnkey employee health centers to immediately treat employees and their dependents onsite or near the workplace. Employee health centers will generate significant savings on medical claims costs. Typical company’s save up to 20% percent of their overall medical claims spend. For example, a company with 2,000 employees can save over $3,000,000 per year.

MCC will provide a health center complete with doctor and all staff for primary care services. In areas where this strategy has been implemented, cost savings have been impressive: Sizable hard-dollar savings have been realized from lower costs for primary care visits, fewer visits to hospital emergency rooms and fewer specialist referrals. Onsite access to care has also increased employee productivity, reduced absenteeism and enabled earlier intervention through onsite capability for disease management and patient education.

Our program works with your existing plan or benefit design and is completely voluntary. Our clients are businesses and organizations with over 1,000 employees. For more information on Medical Care Consultants call us at 877-232-5782 or Send us a Message


Cost Plus Sparks Industry Commentary

Sunday, May 4th, 2014

a1234“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. “– Principal, Benefit Captive Re


Ousted San Benito ISD Clinic Administrator Resigns

Saturday, May 3rd, 2014

VENDOR FIRES BACK: Ousted clinic admin alleges board, administration retaliation


Managing Editor

The embattled administrator of the San Benito CISD on-site health clinic fired back days after the Board of Trustees unanimously voted to part ways with him.

Richard Garza, owner of ISD Managed Care Services and provider of on-site health care for the school district’s employees, submitted a 60-day written notice on Thursday informing SBCISD Interim Superintendent of Schools Dr. Ismael Cantu of his resignation. Such action came after the Board voted unanimously during a special Wednesday to provide ISD Managed Care with a 60-day written termination notice.

At the meeting, trustees including Board President Yliana González, Secretary June Aguilera, Oscar Medrano and Anna Cruz expressed concern with an Internal Revenue Service lien in excess of $315,000 that was placed on the district’s future payments to Garza.

Want the whole story? Pick up a copy of the May 4 edition of the San Benito News, or subscribe to our E-Edition by clicking here.

Latest Court Ruling Gets HealthSmart Audit Step Closer To Becoming Public

Friday, May 2nd, 2014

Company’s options running out

Posted: April 28, 2014 – 5:24pm  |  Updated: April 29, 2014 – 12:29am


 A story more than a decade in the making is a step closer to being told.


Medicare Panel Votes Against Annual CT Scans For Heavy Smokers

Friday, May 2nd, 2014


Yesterday a Medicare panel surprised many in the medical community by recommending against Medicare coverage of annual CT scans for current or former heavy smokers.  The nonbinding recommendation was issued by CMS’s nine-member Medicare Evidence Development & Coverage Advisory Committee.

The vote comes as a surprise for at least two, interrelated reasons.  First, it is squarely at odds with a recent (December 2013) recommendation by the U.S. Preventive Services Task Force that current and former heavy smokers aged 55 to 80 should get scans.  Second, under the Patient Protection & Affordable Care Act that Task Force recommendation means that commercial insurers are required to cover screenings for non-Medicare members without any out-of-pocket cost to the members.  A test typically costs from $300 to $400.

The Advisory Committee acknowledged that a National Lung Screening Trial found a 20% reduction in mortality among current and former heavy smokers who underwent CT scans, compared to those who had chest X-rays.  But the Committee noted that it doesn’t rely on a single trial in formulating national policy.  The Committee was also impressed by the negative effects that often accompany CT scans—particularly the psychological trauma, cost, and unnecessary surgeries that result from false positives.

CMS is expected to issue a proposed decision this November and make a final decision by next February.

Today’s post was contributed by Norman G. Tabler, Jr.