Dr. Benjamin Clinton explains how the poorest school district in Texas solved health care………..
Continue reading Texas School District Explains How They Solved Health Care
Dr. Benjamin Clinton explains how the poorest school district in Texas solved health care………..
Continue reading Texas School District Explains How They Solved Health Care
Blue Cross has given a small school district in deep South Texas a better deal than TRS ActiveCare with over 400,000 members………………. Continue reading Blue Cross Gives Small School District Better Deal than TRS ActiveCare
By Bill Rusteberg
I’ve been dealing with hospital administrators since the 1970’s and during the years since little has changed. I know exactly what the hospital administer will say and do during the negotiation process, their tactics, including the traps they set for amateurs.
Continue reading When Reason & Logic Won’t Win The Argument, Arm Twisting Will
By Bill Rusteberg
Recently I was referred to a large medical group that was interested in learning more about how we help plan sponsors manage their employee health care needs. They were fully-insured with a BUCA and tired of double-digit rate increases year after year.
Continue reading You Don’t Want Me To Know Your Business Because It Won’t Be Good For You!
Amazon is acquiring One Medical for $18 a share, an all-cash deal that values the primary health-care provider at roughly $3.9 billion, the companies said Thursday.
New England Journal of Medicine reports a transformational therapy has effectively cured the Royal Disease………..
Separating The Sheep From The Goats – Matthew 25:31–46
I have hated this business for a long time but I love being an outlaw helping companies escape the prevailing death spiral…………………………..
“Don’t bother doing something unless your radically different from the competition”– Richard Branson
By Bill Rusteberg
Building a Rx benefit plan without a PBM (Predatory Business Model) is beginning to make sense for plan sponsors whose Rx costs are as high as 50% of total plan spend. They no longer view their plan as a health plan but as a Rx plan with health benefits attached.
Continue reading Build Your Own RX Plan – Bypass Predatory Business Models (PBMs)
While chasing a squirrel in the woods, beloved pet dog tore the anterior cruciate ligament in her left knee. Turns out she had better insurance than her master………………………………
Continue reading My Dog Has Better Health Insurance Than I Do!
If Paul Harvey were alive today and had read the following article, he would have found fertile material for his “The Rest of The Story” radio show…………………………
Plan Sponsor Employs Discretionary Authority
Does your plan contain a discretionary authority provision? The government may be taking that away if HR 7740 passes. It will prohibit arbitration in ERISA claims and discretionary authority clauses.
Continue reading Plan Sponsors To Lose Discretionary Authority?
Are PBM’s Adding Another Middleman To Avoid Transparency?
Are PBM’s creating another intermediary in the supply chain to prepare for transparency requirements? They stand to lose a lot if they get regulated on rebates. By creating another organization that’s offshore, they can protect their interests…………….
Continue reading PBM Shell Game – Hiding Fees Through Middlemen
AUSTIN, TX – “He’s turning into a shell of his former self”, his wife cried.
Lee had become so frail that it took every ounce of energy just to hoist himself out of his scooter and into his favorite Lazy Boy.
Formulas for establishing health insurance renewal rates:
Continue reading Underwriting Health Insurance Plan Made Easy
Article Referred By Jody Bright
Pharmacists can now prescribe Paxlovid, Pfizer’s COVID-19 antiviral pill, directly to patients.
Continue reading US Allows Pharmacists to Prescribe Paxlovid Directly
Prescription drugs don’t have to be as expensive as they are. A smart plan sponsor, thinking out of the box, would discover tremendous savings if they seize advantage of opportunities available in the free market.
“Pharmacy Benefit Managers are one of the three most influential opponents of price transparency……………….. If the true cost of a medication were known this would shine a light on the fraud taking place, so the PBMs hide the costs at every turn”
SOURCE: Vitori Health
Twenty years ago, nearly two-thirds of doctors were independent practitioners. Today, only one-quarter remain independent.
Continue reading Only 26 Percent of U.S. Physicians Are Still Independent. Why?
Once Upon A Time there was a young man in dire need of medical care but he had no insurance………….
Protecting patients,
health plans and insurers
across the U.S.
“We engaged Koehler-Fitzgerald in 2015 to represent covered employees of health plans we provide administration to that have adopted reference based pricing. They have been very responsive to the needs and questions presented by plan sponsors, plan members, and our staff. Their success rate with balance billing issues presented to them has been in excess of 99% by any standard of measurement. Knowing that every participant has legal representation from a high quality, experienced law firm provides our client plans and employers confidence that their employees will be properly protected from the many aggressive balance billing practices that a small portion of hospitals and other medical providers attempt to employ. They have been shown to be the most effective solution to the only real impediment to adopting reference based pricing.” – Jim Farley, J.P. Farley Corporation
Continue reading Law Firm Manages & Reduces Risk For RBP Plans
A national poll conducted by the Molly Mulebriar organization found 99.99999% of Americans hate their health insurance. The primary reasons cited include affordability.
Continue reading Poll – 99.999% of Americans Hate Their Health Insurance
Asserta is offering investors an opportunity to share in a fast growing segment of the American health care system of finance providing employers significant savings on health insurance costs while removing financial barriers and improving member experience for working Americans ………………
Continue reading Asserta Seeking Investors @ $7.95 Per Share
Specialty Drugs Have Consequences
During the interview process Joe Sixpack learns the position pays $35,000 plus benefits. Little does the employer or Joe know the true cost was going to end up being $650,000…..the equivalent of 18 jobs………..so to keep from bankruptcy the employer must reduce his workforce by 18 (hopefully non-essential) employees and freeze wages for everyone else ………….or move his manufacturing business to China and his $685,000 per year employee to unemployment.
Continue reading Specialty Drugs Are Bankrupting Health Plans
MyHealthGuide Source: Voya Health Solutions*, 7/5/2022
Voya Health Solutions* is pleased to announce their continued expansion into the mid-market beginning with quoting on July 1, 2022.
Continue reading Voya Health Solutions* Expands Stop Loss Presence in The Mid-market
“The supposed firemen are arsonists…getting rescued and then robbed shouldn’t happen”.
Rancho Pescadero Wellness Center offers a unique approach to wellness…………….
Continue reading Finally, A Wellness Program That Makes Sense
This blog entry is directed towards PBM experts who are not PBM’s or employed by a PBM. We are searching for the truth about the deep black vortex of the PBM world……………
“Reimbursements for overrides are taxable if not provided a written plan as required by Code Section 105. If taxable, reimbursements should be reported on employee W-2s and all applicable income and employment taxes should be withheld and reported as required by the IRS….”
Continue reading Carving Out Specialty Drugs May Have Consequences
“Pssst….Godfather, We’ve Been Exposed!
The following account is based on a true story.
If a Reference Based Pricing plan pays medical caregivers 120% of Medicare, what is the Plan Sponsor paying?
“Prudent plan fiduciaries will establish and adhere to a formal, written policy to ensure compliance with the New Disclosure Rule. Indemnification and limitation of liability provisions in service provider contracts should also be revisited relative to this new rule.”
Continue reading Brokers Rejoice! Compensation Disclosure Not Required For Non-ERISA Groups
Eagle Pass Independent School District has got to be paying more for health insurance than any other school district in Texas…………………..
Continue reading Texas School District Wins “Highest Cost Health Insurance” Award
By Doug Aldeen
Sunday morning bathroom read (Happy 4th of July): Slowly but surely (more like a glacial pace) the python like grip of the industrial medical sick complex is loosening… .
Continue reading Aldeen’s Sunday Morning Bathroom Read – Happy July 4 Edition
“Some things are worth getting mad about. The hospital cartel is using taxpayer dollars to help crush the middle class and rob lower-income families of upward mobility…………Wealthy hospitals took billions of taxpayer dollars meant to protect struggling hospitals — and then some billed poor families or even sued patients.” – State Treasurer Dale R. Folwell, CPA
Continue reading Elected Official Mad As Hell – Hospital Cartel Crushing Middle Class
Dogs are “superior smellers” and are already used to detect what the human nose typically cannot from diseases, such as Parkinson’s, cancer and diabetes, to drugs and explosives in public places, according to the American Lung Association.
California will become the first state to remove immigration status as a barrier to health care, making all low-income illegals eligible for state-subsidized healthcare regardless of age.
4 Out Of 5 Americans With Diabetes Went Into Debt To Pay For Insulin, New Survey Shows
By Deb Gordon
Amidst rising inflation, Americans are feeling the squeeze of higher prices on everything from gas to groceries. But when inflation bumps into the already rising cost of drugs such as insulin, the impact can be serious and the stakes are high.
Continue reading Dr. Banting Patented Insulin Over 100 Years Ago For $1. What Happened?
“What! I thought It was The French Connection!”
A county government in New York has been accessing Canadian prescription drugs through their self-funded health plan since 2004 with savings in the millions of dollars. Now we see more employers considering the same by moving away from traditional Predatory Business Models (PBM’s) as drug prices reach unaffordable levels in this country.
Continue reading More Plan Sponsors Eye The Canadian Connection
We are looking for the perfect TPA. Some of the qualifications are memorialized here: Selecting a Third Party Administrator.
Holms & Watson Remain Stumped
SOURCE: Vitori Health
A report by the PBM Accountability Project reveals the details of PBMs’ “evolving business models and revenue.” Despite the available financial data, the authors could not identify “the source of nearly 40% of PBMs’ total gross profit.”
Continue reading Predatory Business Model (PBM) – The Case of The Missing 40%
By Bill Rusteberg
“What color is that orange?” asks the first underwriter. “It’s yellow!” says the second underwriter. “It can’t be! It’s an orange!” responds the first.