By Molly Mulebriar
Recently I was asked to assist a speaker in preparing for a talk to be given to an audience of hospital administrators at their annual convention. The topic was “Why You Should Be Prepared For Direct Contracting with Local Employers.” So I wrote the following advice:
The plan conducted a claims audit in 2004 and found that Great-West had paid almost $1 million in out-of-network claims in full as billed, rather than as a percentage of the usual, customary and reasonable charge.
“There is no justification for these outrageous rates,” says Prof. Anderson, “but no one tells hospitals they can’t charge them. For the most part, there is no regulation of hospital rates and there are no market forces that force hospitals to lower their rates.”
Editor’s Note: “Market forces” and “Regulation of Hospital Rates” are not synonymous.
Free Health Care For All
To finance the project, Colorado employers would pay nearly 7 percent in a payroll tax. Employees would pay 3 percent or more of their gross pay toward the health plan. The self-employed would need to pony up 10 percent of their annual net income…..
David Belk
Greetings, I hope everyone is enjoying this holiday season.
About three weeks ago I was interviewed for a show called Mind the Business where I discussed three stories that had been in the news recently about fraud and conflicts of interest in healthcare.
If hospitals defraud Medicare, could they also defraud private pay health plans too? Most plan sponsors don’t audit their health care claims either because they never have “so why start now?”, or they are prohibited from doing so through contracts of adhesion i.e, managed care contracts.
As former healthcare executives ourselves, we understand the challenges leadership faces to be successful in this fast-paced industry.
We use our industry expertise to help you develop and execute strategic plans that evolve your business.
The most shared article on this blog for 2015 – Lawsuit Exposes Insurance Industry’s Best Kept Secret
RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.
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You may know a hospital by its general reputation, but is it really the best place to go for the specific type of surgery you need? And is it true you “get what you pay for” in health care? Do higher prices mean higher quality?
Risk Manager: “Excuse me Mr. Fox, there are some hens missing”. “Can you check the security cameras to see what happened?”
BCBS: “Sorry, the images on those cameras are proprietary”. “But here is a letter stating we didn’t steal any hens.”
Martin Shkreli, the boyish drug company entrepreneur, who rocketed to infamy by jacking up the price of a life-saving pill from $13.50 to $750, was arrested by federal agents at his Manhattan home early Thursday morning on securities fraud related to a firm he founded.
Shkreli’s extraordinary history—and current hold on the public imagination—makes the case more noteworthy than most involving securities fraud. The son of immigrants from Albania and Croatia who worked as janitors and raised him deep in working-class Brooklyn, Shkreli both epitomizes the American dream and sullies it.
New study claims that as much as 80 percent of employers face prescription drug abuse by workers.
Researchers have compiled data on $682 billion worth of claims to look at the truth behind medical costs.
The laptop computer was taken from an unlocked treatment room “off of the inner corridor” in the hospital’s radiology department………….
Government punishes hospital with $850,000 fine……….
Hospital passes on the cost to consumers….……..
The fines for not having prepared a risk assessment will always be more expensive than quietly surrendering to extortion.
Symposium: Contraceptive mandate cases – why the Supreme Court will instruct lower federal courts to stop second-guessing religious beliefs : SCOTUSblog
By Drew Altman
Kaiser Family Foundation analysis of data from the Centers for Medicare and Medicaid Services and Truven Health Analytics showing that drugs account for 10% of U.S. health spending but 19% of employer insurance benefits.
This abbreviated video summarizes ten benefits strategy in three minutes:
https://www.youtube.com/watch?v=rMXukAf_4ok&feature=youtu.be
More than 3 in 5 U.S. companies are self-insured, and self-insurance is almost universal among large employers………Roughly 60% of members at Aetna, Anthem and Cigna are in ASO plans
By Bill Rusteberg
The McAllen Independent School District’s (MISD) self-funded health plan is administered by Blue Cross & Blue Shield (BCBS). BCBS traditionally utilizes their own proprietary managed care network and typically requires their network access exclusively as part of their bundled ASO services.
Enthusiastic Islamic Insurance Brokers Tout Infidel Insurance Coverage
Takaful, or Islamic insurance, is a cooperative scheme, where in which the participants pay a premium in the form of donation or tabarru in a common pool in return for the ability to draw upon that pool upon a valid claim.
“The hospital was forced to file suit against 10 individual patients. In the end, the insurance companies payed the requested amount, the individuals paid their out-of-pocket expenses and eventually the repricing company stopped the practice.”
Editor’s Note: This article does not tell the whole story and may be misleading. We called the city for more information and found this to be an interesting case study; City of Richmond eschews managed care contracts and instead implements a reference based pricing model for their self-funded health plan in a local one hospital town. Hospital pushes back hard, city stands firm and to this day continues to pay medical caregivers through their reference based pricing model. This is more evidence that Cost Plus / Reference Based Pricing will work only as long as the Plan Sponsor is “all in” and willing to take a stand.
“Fed up with soaring costs, Dallas and 30 other North Texas municipalities are asking hospitals to submit bids indexed to federally controlled Medicare prices to cover the cost of care for city employees”
“This illustrates how PPOs have failed to control Hospital Claims Costs for plan sponsors, and how this model is your best resource in preserving your client base and employer sponsored health plans.”
– Magellan Risk Management
“Oscar isn’t the only insurer to slash brokers’ commissions. UnitedHealthcare cut them to $10 per contract per month from $15…”
Those of us who fought co-Presidents Bill and Hillary Clinton’s 1993-4 attempt to put every American in an HMO thought we had won that battle. We were wrong. President Obama is achieving their goal with Obamacare.
Andy Puzder, CEO of Carl’s Jr. and Hardee’s parent CKE Restaurants, says that just 420 of 5,453 full-time workers offered a $5,500-deductible plan were willing to pay the $1,116 premium. The New York Times reports that insurance take-up by fewer than 10% of low-wage workers is commonplace.
Wendy’s (NASDAQ:WEN) initially expected its health insurance tab to jump by $25,000 per restaurant, but cut that to $5,000 after finding few interested employees.
In 1973, 75% of all Americans were covered by private health insurance (https://www.ssa.gov/policy/docs/ssb/v38n2/v38n2p21.pdf)
In 2014, 41 years later, private insurance covered 70.4% of all Americans. (https://www.ssa.gov/policy/docs/ssb/v38n2/v38n2p21.pdf)
Health Republic Insurance of New York was one of 23 nonprofit health cooperatives created nationwide by the Affordable Care Act and was, by far, the largest of those to fail.
