“PBMs don’t stop at legal money-making schemes……….. undisclosed rebates, artificial price inflations, kickbacks, steering, and other deceptive practices.”

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Agents, brokers and consultants, once so welded to the status quo, are now some of the most vocal and ardent supporters of the movement away from PPOs……………

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“The health care game is rigged,…………………“That’s why we don’t play by their rules — and neither should you.”

Instead “Name your own price for health care services” (reference-based pricing strategy), along with rigorous auditing of facility claims.” 

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President Trump Beating Up On PBMs In Oval Office?

“This system is completely broken … It is layered and layered with conflicts of interest. I don’t care who the PBM is.”

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If it’s not an emergency, Blue Cross Blue Shield won’t pay……………

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In health care size make no difference……or does it?

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The insurer claimed—I’m not making this up—that its customers bore some of the financial responsibility for being ripped off because they weren’t paying close enough attention to what BCBSM was doing………………..

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The health care industry is closely watching a recent decision by the Texas Supreme Court that some say could have broader implications on how hospitals and health insurers negotiate their rates………………..

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TAGCO RiskManagers, LLC (TAGCO) was formed by industry insiders as a resource for political subdivisions seeking solutions to rising healthcare costs…………………………

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We have the expertise, experience and bulldog tenacity to do the job and do it right……………………….

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Marsh has launched a new insurance product to provide financial protection to US-based businesses and their global operations affected by an infectious disease outbreak.

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“Those who have data win. Those who have good data win a lot. Those who have real time data win all the time” – John W. Richards Jr, M.D.

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Health care reimbursement in the United States usually focuses on the clinical encounter, at a physician office or hospital. This reflects a belief that care is best offered there, even when evidence says otherwise………………

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“We are trying to address the fact that, whether you like it or not, our undocumented community needs the care, and we are paying for it anyway………………..California needs to be a laboratory for social change by taking the lead on progressive causes.”

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The US Court of Appeals for the Third Circuit has held that anti-assignment clauses in health plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) generally are enforceable.

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Article referred by David Wendel

The Texas Department of Insurance (TDI) has a new  website that provides cost information on more than 200 of the most common medical procedures, including many tests, surgeries and office visits.

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Question: How do we know we are doing better (saving money) this year than last year?

Answer: What was this year is last year plus or minus this year’s change.

Question: Then if change is the only constant why do we need to measure it? You don’t know if something is better if you didn’t know how to measure what it was before.

AUTHOR UNKNOWN

By Molly Mulebriar

The City of New Braunfels RFP recently hired an insurance consultant to assist the city in a competitive RFP process for their employee health & welfare plan. Or did they hire two?

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Vermont initiative creates a wholesale importation program to purchase high-cost drugs in Canada, where they often sell for less…………………Will retail Rx outlets then advertise and export these cheaper drugs from Vermont to the rest of the county? Could be a fantastic Rx mail-order business domiciled in Vermont…………….

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Turning Bronze Plans into Gold Plans at Bronze Plan costs is a common but unspoken strategy……………

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A Texas doctor used his million-dollar private jet or drove in his Maserati, which were both emblazoned with his initials “ZQ” between his offices in the Rio Grande Valley and San Antonio…………he purchased private jets, luxury vehicles, clothing from high-end retailers such as Louis Vuitton and exclusive real estate located throughout the United States and Mexico………..all garnered through his successful clinic operation in deep South Texas………………

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NATIONAL ASSOCIATION OF PREFERRED PROVIDERS (NAPP) Fee Schedule:

☑ Medicare plus 25% or 80% of billed charges, whichever is less.

☑ THREE RIVERS PROVIDER NETWORK (TRPN) – PPO Fee Schedule:

125% of the existing Medical fee schedule as total reimbursement for covered services less applicable co-payments, co-insurance or deductibles.

IMAGINE A ONE  OR TWO PAGE HOSPITAL CONTRACT INCORPORATING THESE FEE SCHEDULES…………………….

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In a previous RFP for Section 125 Administration & Products, a bid was awarded in March 03-18-S40-229. Now we see the City of McAllen is re-bidding again. What happened?

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Republicans and Democrats blame each other for the great American health care failure. But isn’t it true that once government gets involved in anything costs go up? For example, food costs are higher because of the food stamp industry wherein recipients really don’t care what the cost of food is since its free. And how about college tuition? With rampant student loans students (and their parents) don’t feel the financial pain……………until much later. Isn’t the same true for the high cost of health care?

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“I’d like to call the employee benefits “advisory” space another one of the most respectable professions in existence, but I can’t. Advisory is in quotes because that’s not really what it is. Many employee benefits consultants are brokers, a line of work that differs sharply from what it means to be a true advisor.”

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The Donna Independent School District in deep South Texas has had plenty of bad press during the past several years – board members sent to prison, hiring of convicted felons, lawsuits and counter lawsuits, sanctions by the Texas Education Agency, and now TEA oversight (Texas Border School Scandal Highlights Culture of Corruption – Breitbart).

Now we learn the DISD is again seeking yet another insurance consultant. This will make the sixth “insurance consultant” / brokers utilized by the district in less than three years………………..

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He lasted 27 days without insurance…………………….

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RBP can save a self-funded plan a lot of money and create immense opportunity to permanently improve the benefits for employees in that plan; however, RBP can also create an environment for conflict, individual tragedy for plan members, and protracted litigation…………….

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The 60 Minutes story (www.cbsnews.com/video/the-problem-with-prescription-drug-prices/) aired last night illustrates the continuing gamble most plans sponsors take in not addressing high cost specialty drugs. There is not a group in this country that offers ACA complaint health care benefits for their employees that is not at risk of bankruptcy, yet they continue to gamble they will beat the odds.

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Last week a story ran in the Victoria Advocate (Victoria, Texas) that told the sad story of mean insurance companies bankrupting a new start up business whose goal was to service the dire health care needs of locals. See Mean Insurance Companies Bankrupt Free Standing ER.

Now the same newspaper, different reporter, spins the story in a different direction…………….

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Bill would allow more small businesses, including self-employed individuals, to form health plans on the basis of industry or geography…………………

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POSCA℠  is a first in class method for processing health care claims…………………..

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William Lee “Bill” Ebaugh

I have met a lot of people in the insurance business over the years, but Bill Ebaugh stands out. His knowledge and connections within the insurance industry was amazing. He was a master salesman, story teller, and visionary. His life’s experiences were something out of a movie. He attracted the best in everyone he met.

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In today’s Victoria Advocate newspaper (Victoria, Texas) there appears an article about a free standing ER closing down because the have “been having problems with insurance companies.” Actually the problem is not with the insurance companies. Its with hospitals gaming the system. Consumers equate free standing ERs as urgent care centers paying for services with other peoples money. An “office visit” there can cost several thousands of dollars for something as simple as a cold, insect bite or sprained ankle. The cost is so high and the profits so great it takes only 6 or 7 customers a day to reap a profit.

Yet you read the story below and come away thinking the mean, uncaring insurance companies seeking to pay as little as possible are to blame. BTW – insurance policies under the ACA cover emergencies.

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Health care is the focus of a national debate that never seems to end. So called “experts” on health care delivery offer all kinds of suggestions and advice to solving the health care financing crisis in this country yet they won’t admit the journey towards solving the crisis will soon end.

In my circle, for example, the discussion centers around performance based medicine, reference based pricing strategies, point of service claim adjudication/payment, wellness programs, direct contracting, value based outcomes and more. But all secretly recognize there is an Elephant in The Room.

The Elephant in The Room is the inevitable coming of a single payer health care system to this country. It’s only a few elections away and we all know it. Americans are fed up with the high cost of health care. Many employers  are simply running out of money to pay for it. The American middle class who has been bearing the brunt of the cost is a vanishing, diminishing class. Hospitals and third party intermediaries continue to raise pricing, compounded year after year well beyond true inflationary pressures. Drug manufacturers are reaping record profits on drugs that sell as much as 80% – 90% less overseas.

The experts mentioned above have the answers to solving our health care crisis and the proof to go with it but few seem to be listening………….

– Bill Rusteberg

The following article is about that Elephant:

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The Academy of Managed Care Pharmacy (AMCP) supports the use of therapeutic interchange programs as a part of a comprehensive approach to quality, cost‐effective patient care. Therapeutic interchange is the practice of replacing, with the prescribing physician’s approval, a prescription medication originally prescribed for a patient with a chemically different medication. Medications used in therapeutic interchange programs are expected to produce similar levels of clinical effectiveness and sound medical outcomes, based on available scientific evidence.

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“Based on court cases (cited in the paper), it seems apparent TPAs can and do hide ‘undisclosed’ administrative compensation fees within medical claims payments. These undisclosed fees, which can account for 30 to 60 percent of a plan sponsor’s health claims expenditures, are usually siphoned into the TPA variance account through ‘retention reallocations’ and ‘cross plan overpayment’ offsets, among other techniques………………..

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The Texas Supreme Court has ruled that a hospital in Cypress, Texas, must disclose its negotiated reimbursement rates with public and commercial health plans as part of the discovery process in a suit filed by an uninsured former patient………………

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