Is Medicare +25% Reasonable?

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Is 125% of Medicare a reasonable reimbursement rate? Patrick Rooney thought so back in the 1980’s. Many believe it still is.

Several of the BUCA’s pay less than that for out-of-network provider pricing. We have seen some of the BUCA’s pay out-of-network hospitals 105-110% of Medicare. 

Our book of business primarily employs reference based pricing strategies paying hospital / facilities 120% of Medicare since 2007. – Bill Rusteberg

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Insurance Companies & Private Hospitals Facing Off In Houston

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Your Billing Is Too Damn High!

According to the Houston Chronicle, at least a dozen lawsuits have been filed in the city in recent years over what insurers claim is an incorrect practice: private hospitals offering patients lower rates that compete with “in-network” facilities by billing the insurance company more.

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The Next Innovation In Controlling Healthcare Costs

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Many Texas employers have been using reference based pricing strategies since 2007. These early adopters have enjoyed great success in containing medical costs. All have succeeded in beating medical trend, maintaining static costs while improving benefits.  

Markets sometimes take time to adapt, as the status quo is always in the best interests of vested interests, including insurance brokers, carriers, TPA’s, hospitals and managed care organizations. Now we are seeing reference based pricing strategies gaining rapid market growth. For example the state of Montana adopted a reference based pricing for the state’s employees just this month. – Bill Rusteberg

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Politician Attorney Fights Insurance Companies

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Politician-Attorney Fighting For Plaintiff’s Lawyers

It’s all about protecting one’s profession and not at all about protecting consumers. It’s all about government taking care of people who are too stupid to take care of themselves. It’s all about government interference in a free market economy where sellers and buyers choose who to do business with. 

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Insurers Pushing For Higher Rates To Pay Health Care Partners

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“Insurance companies continue to look out for their medical provider partners. Secretive managed care contracts between these conspirators continues to assure annual increases in reimbursement rates, year after year. “

“It’s true that 90% of health insurance rates go to pay medical caregivers. The more providers charge for their services the higher the rates need to be. The only method to reduce health insurance costs is to reduce fees paid to medical caregivers as the State of Montana has done this year under the state employee health plan. It’s that simple” Homer T. Farnsworth, M.D.

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Plan Sponsors Beware! Are You Next?

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Mike Flores

“According to industry experts, more and more CEO’s, CFO’s and Plan Administrators are exposed to tremendous liabilities due to poorly managed or “Head in the Sand” monitoring practices. As we have written about and predicted, this is evidence of the growing trend of self-insured health plans being exposed to tremendous liability by TPA’s.”

“These cases also illustrate an ironic twist, in many cases, the ASO agreements prohibit the plan from auditing the claims that the TPA’s are paying on behalf of the self-insured plan, which on its face, seems to be a remarkably absurd clause that any plan sponsor would agree to sign.”

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TPAs Developing Innovative Strategies To Control Health Care Costs

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KGA has identified providers that offer transparent, greatly-reduced, all-inclusive cash prices. These providers allow KGA to utilize this pricing because the claims are paid quickly and at 100%. Plan participants utilizing a Kempton Premier Provider for a covered medical procedure benefit by incurring no out-of-pocket costs and the plan receives substantial savings. It’s a “win-win” for all parties involved.

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Insurance Consultant Sentencing Postponed to Sept. 28

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William Haff

A 46-year-old San Antonio independent insurance consultant William O. Haff is facing up to five years in federal prison after pleading guilty to his role in a kickback/bribery scheme earlier this year involving local school district insurance plans. Original sentencing was scheduled for July 13 but has now been postponed to September 28, 2016.

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Reference Based Pricing Market Blitzkreig

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“As more employer groups have adopted this strategy, hospital and provider groups have begun to take notice and push back. Therefore, the future of these plans is still uncertain” – Scott Aston

Editor’s Note: The author is mistaken. The future of Reference Based Pricing plans is not at all uncertain. PPO’s are going away, replaced with common sense and prudent business practices. Plan Sponsors are on to the PPO game and don’t like what they see. They are mad as hell and not taking it anymore.

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A Review of 4 Key Cases & New Laws Affecting Employers

coned A range of legal decisions and fact sheets released by government organizations in recent months are expected to have an impact on employee benefit plans. In the wake of these cases and related guidance, advisers and employers should review their policies on topics such as cash-in-lieu of benefits, pregnancy discrimination, health questionnaires and arbitration agreements.

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No, We Won’t Treat You Unless You Pay More!

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By Molly Mulebriar

When a hospital refuses to accept a patient because their health insurance plan limits allowed charges to 120% of Medicare reimbursement rates, and instead offers to discount their charges by 15%, one wonders how much more will the patient be asked to pay.

Of note is the hospital routinely accepts 100% of Medicare from Medicare patients.

Since hospitals never disclose their charge master rates, agreeing to pay in advance for medical services on the basis of a 15% discount off an unknown number makes no sense at all. We don’t agree to purchase any other goods or services on that basis so why would we do so for health care?

Fortunately in Texas, there is a law that requires hospitals to provide a cost estimate in advance of services rendered, unless the charges are for immediate emergency care.

According to the Texas Insurance Department website “Texas law gives patients the right to request estimates of charges. Doctors and other providers and health plans have 10 days to give you the estimates.”

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Belk Digs Into UHC Finances – Questions Motive To Leave ACA Exchanges

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“United Health Care announced last fall that they would be pulling out of the ACA exchanges because the Obamacare policies were costing them too much money. I thought that was a curious announcement since, according to their financial statements from last year, they appeared to be doing quite well.”

“I’m really starting to wonder if I’m the only person who ever checks financial statements” – David Belk, M.D.

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Jeff “John Hancock” Bernhard Leads Health Care Revolution

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“Jeff Bernhard is one of the rare senior executives who has left one of the big national health insurance carriers to truly solve the issues the large carriers mainly pay lip service to. He’s running Continental Benefits that is described as a “super TPA” as they go beyond what traditional third-party administrators do and apply some of the proven Health Rosetta approaches.(Super TPA – The Purple Cow of Health Care) They are growing rapidly and are one to watch.” – Dave Chase, Forbes Contributor

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Fabricated Shared Savings Schemes Continue – Plan Sponsors Beware!

mulebriarThe scheme continues. Shared savings off imaginary numbers through PPO discounts negotiated in secret and subject to gag orders, effectively screws consumers by driving costs up. There have been numerous lawsuits in recent years against Cigna, Blue Cross, Aetna and others with pleadings summarizing identical complaints.

Plan sponsors are at extreme risk as evidenced by the following article by Mark Flores. As plan fiduciaries they are liable for potential lawsuits. Hungary attorneys and outraged consumer groups are beginning to take note – Molly Mulebriar, Waring, Texas

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