October 2022 – Risk Managers

Wife Saves Husband’s Ass

Article Referred By Bob Calvisi

Kalsariya had no way of knowing then that she was embarking on a crusade that would take over a year, send their bill to debt collections, lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

Major BUCA Throws In The Towel

Blue Cross of Montana throws in the towel and joins the Reference Based Pricing movement at the expense of their provider partners…………………

If TRS ActiveCare Adopted This Strategy…..

If TRS ActiveCare would adopt this strategy there would be no commercial vendor able to compete competitively. The only difference would be in fixed expenses which TRS ActiveCare would win hands down. Commercial vendors have enormous expenses TRS ActiveCare doesn’t.

Blue Cross Competes With Legacy RBP Vendors

If you can’t beat them, join them. A stirring giant ends hibernation in Montana………….

Aldeen’s Sunday Morning Bathroom Read

Price maker vs. price taker- Montana tweaks its RBR model

Doug Aldeen ERISA Healthcare Attorney and General Counsel

“…Montana is positioning itself to tweak its model, just as more states and employers, seeking to cut costs, consider adopting it. That has health economists and those working to lower hospital prices elsewhere wondering whether the state is once again moving ahead of the curve — or setting itself up for a setback.”

BCBS Reference Based Pricing TPA Admin. Agreement Exposed

Aldeen’s Sunday Morning Bathroom Read exposes BCBS Admin. Agreement with the State of Montana. BCBS was recently awarded a contract to administer the state’s Reference Based Pricing plan.

If Peter Had Only Kept His Mouth Shut!

Dr. Peter McCullough, one of the most respected doctors in the world, has been a beacon of light throughout this pandemic. His reward for speaking the truth? He’s being stripped of his credentials.

Hospital Care Systems – Four Basic Models

These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus…..

Majority of Americans Do Not Approve of U.S. Healthcare System

57% of Americans Want Uncle Sam Health Insurance

When it comes to solutions for the healthcare system, Americans are more divided. Younger Americans, those between 18 and 49, are more likely than adults older than 50 to believe it is the federal government’s responsibility to make sure all Americans have healthcare coverage. Overall, two-thirds of adults believe this, up from 57% in 2019 and 62% in 2017.

Oh Oh, Are We In Trouble?

RBP Non-ERISA Plan Sponsor Weeps Under Cross Examination

According the the American Hospital Association, “Only employer-based plans regulated under ERISA may use reference-based pricing as a comprehensive payment strategy.“

More Americans Will Qualify For OPM in 2023

SOURCE: SOLVING THE HIGH COST OF HEALTHCARE WITH OTHER PEOPLE’S MONEY

The overarching goal of Obamacare was to expand access to health insurance, and to make it affordable.

Return From Exile

“We’re leaving TRS ActiveCare and you’re not welcome back for five years!” says Little Rabbit Independent School District.

The Gathering Storm: The Threat to Employee Healthcare Benefits

Employees facing unaffordable premiums and out-of-pocket burdens may decide to self-select out of group coverage in favor of individual policies, Medicaid (if eligible), or no coverage (uninsured).

A Capitated PCP, ER, Lab & Radiology Benefit

An attractive, low cost, capitated employer sponsored plan for $125 per employee per month covering primary care, ER visits, lab and radiology with no co-pays, deductibles with no restrictions on pre-existing conditions?

Why Ask For Quotes When You Don’t Need To?

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

Johnny Agent calls on an employer asking permission to quote on their self-funded health insurance plan. “Sure, here’s our census data, claims information, benefits summary, and current premium” says the CFO.

University of Houston Opens DPC Clinic

The clinic is the medical school’s first in a planned network of DPC clinics…..Startup costs for the pilot clinic are funded by a $1 million gift from The Cullen Trust…….patients receive customized, comprehensive primary care services for a flat, affordable membership fee of $60 per month….

Profiteering In Healthcare

“Let’s take our medicine that costs $1.20 and sell it for $130! And let’s have government tell consumers it’s free! And while we’re at it, lets tell them two doses offers very limited protection, if any, so make sure you take more doses, it’s free. Otherwise you may die sooner than later……………..……..later is better. Death is bad, life is good.

San Antonio General Agent Advertises The Old Fashion Way

See where we’ve been, how far we’ve come and how we lead change……..

Mass Exodus of Dependents Begins

Dependents Seek Coverage in The Promised Land of Gov’t Subsidies

“As a result of the expanded eligibility for federal tax credits, employer plans may see a decrease in enrollment of spouses and dependent children in their health plans….

How to Make Reference-Based Pricing Work For Your Plan

Mixing Reference Based Pricing with direct agreements is like mixing oil and water……………..

Mining For Gold In Health Care Finance

Health Care Disruptor Discovers Mother Lode

WE DUG IN DEEPER………………..HERE’S WHAT WE FOUND.

Thousands of pages, hundreds of documents, reams of case law, and more hours than we cared to count later…Somewhere deep in the research, we found it……………..

Finding Found Money

“Hospital Assistance Program has provided proven results through their efforts since 1990. Their recovery rate is excellent. This program also offers solutions for the patient that helps ease their mind.”

Rx Patient Assistance Program

AbbVie is committed to helping patients get the medicines they need. That’s why we offer patient assistance programs that provide free AbbVie medicines to qualifying patients. Our Patient Assistance Programs are intended for people that live in the United States, have limited or no health insurance coverage and demonstrate qualifying financial need. In 2020, we assisted nearly 155,000 people.

Individual Coverage HRAs See Triple Digit Growth, Continue to Expand Access to Care, New Report Shows

HRAs are doubling on average among all states, with significant growth across all industries, types of employers and employee groups. 92% of adoption is happening among companies with 20 or fewer employees…………………

Government Mandates Injections For Kids

What’s next, a Broccoli Breakfast mandate?

Health In Tech

Power On Your Health Plan

Self-Funding Reimagined for Small Groups

The process of traditional self-funding is complex and overly complicated for everyone involved, costing both time and money. Health in Tech (HIT) is the industry-leading insurtech company that delivers disruptive innovation that reimagines self-funded health plans.

Adam Ruins Everything

Texas Screws Public School District Employees

If you are a full-time state employee lucky enough not to be a public school district employee Texas taxpayers will contribute $7,471.20 per year towards the cost of your Blue Cross Blue Shield health insurance for the 2023 plan year. But if you are a Texas public school employee the state of Texas contributes only $900 towards the cost of your Blue Cross health insurance, a funding level which hasn’t changed in over 20 years.

Hospitals Play Hide & Seek

The hospital price transparency rule, which took effect in January 2021, requires hospitals to publish machine-readable price lists and display rates for medical services in a format that allows consumers to comparison shop. Insurers are now required to disclose rates they negotiate with providers.

Tx. Senate Bill 1444 Survey Results Due Nov. 1

Senate Bill 1444 was enacted in the 2021 Texas legislative session that amends law relating to participation in the uniform group coverage program for school employees. Senate Bill 1444 mandates a study with assessments to be conducted on the health care needs and health coverage options available to employees of Texas public school districts including charter schools.

Ozempic: How a Diabetes Drug Became the Talk of Hollywood, Tech and the Hamptons

Placebo Sisters – Clinical Trial Control Group Proves Placebos Don’t Work

At least once a day, Nancy Rahnama’s clinical nutrition practice in Beverly Hills, Calif., gets a call from a patient looking for a diabetes drug that they’ve heard can help them lose weight fast.

Employers – It’s Time To Help Hospitals Achieve Their Charitable Mission!

*Attention Employers, Give Me Your Poor, Your Tired, Your Huddled Employee Masses………….*

Of the more than 100 million Americans living at or below 400 percent of the Federal Poverty Level (e.g., a family of four with a household income of $106,000 or less), many might not realize they may qualify for low or no-cost medical care. Most likely, their employer and health plan sponsor are unaware of this opportunity as well.

Student Accident Coverage For Texas School Districts

Student Accident insurance coverages available:

Excess/secondary student accident insurance coverage
Deductible and coinsurance options and sub-limits can be added on certain internal benefits, such as physical therapy, orthopedic devices, etc.
Fully insured or self-funded options available

Free Insurance For Economically Disadvantaged Family Members

Those impacted by the family glitch will have important new options to consider when open enrollment for 2023 marketplace plans begins on November 1.

EXODUS

Historic Exodus From Group Health Plans

Free, or near free health insurance extended to millions of Americans by Biden administration with the elimination of the “Family Glitch” will forever change group health insurance.

CVS Fires Nurse Practitioner

Paige Casey – Child Loving Nurse Practitioner

A Virginia nurse practitioner has filed a lawsuit against the CVS drugstore chain after she claims the company fired her for refusing to provide abortion-inducing drugs, a service that violated her religious beliefs.

We Want Your Stop Loss Business!

No participation requirements, immediate firm quotes, RBP with PPO wrap, no employee applications required (coming soon), direct contact with underwriters…………………

The Difference Between a Broker & Consultant

Health insurance commissioned brokers do everything possible to control their turf while sitting on the other side of the table.

Federal Court Finds Key Part of ACA’s Preventive Service Mandate Unconstitutional

WLG (Wagner law Group) / Sep 21, 2022 / / Read Article

A Texas federal district court, in Braidwood Management, Inc. v. Becerra, has held that the Affordable Care Act’s (“ACA’s”) requirement that most group health plans and health insurers cover certain recommended preventive services without cost-sharing violates the Appointments Clause of the U.S. Constitution.

The Only Healthcare Provider Revolutionizing Healthcare?

EZaccessMD is the only healthcare provider that is revolutionizing the healthcare industry by combining traditional telemedicine with mobile urgent care.

Medicare Costs to Go Down in 2023

Lower-than-expected spending on an expensive drug and other things means beneficiaries will pay less next year.

Araya PBM Touts Superior Contract Terms

Several years ago, a team of industry veterans founded Araya. We founded our company based on the idea that all discounts and pharmacy rebates should be passed on to the client – a full pass-through model. Today, our team of licensed pharmacists with decades of PBM experience remain committed to this model.

Working The Spread

This graph represents all you need to know about what’s driving healthcare costs in this country.

School District Learns PPO Allowed = 338% of Medicare

Interesting results of a claim study on the Edinburg Independent School District’s self-funded health plan several years ago show the Medicare equivalent reimbursement rates compared to the district’s PPO allowed amount.

Blue Cross Trashes PPOs

“This is part of an overall national trend to move away from PPO plans that come with high costs to consumers and offer little in the way of coordinated care”

– Blue Cross & Blue Shield of Illinois

Do Hospitals Lose Money On Medicare?

“Unless hospitals are committing fraud in their reporting to Medicare, their rates cover their costs and profit. To then complain that getting paid more than double that is a “hardship” is laughable. I spent years inside hospitals finances as a consultant. With very few exceptions, they’re rolling in the dough while being incredibly inefficient. It’s remarkable how they’ve managed to perpetuate the narrative of “losing” money on Medicare. Have to hand it to their PR/marketing departments & lobbying arms for pulling that off. The consequences couldn’t be more devastating for the middle class.”

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

By Reed Abelson and Margot Sanger-Katz

Oct. 8, 2022

The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.

New Direct Primary Care Program For Houston Employers

A new Direct Primary Care employee benefit program for Houston employers. Convenient clinic locations throughout the Houston metroplex…………………..

Battle of The Blues Heats Up

In a recent blog posting titled Battle of The Blues we discussed the peculiar effects of Texas Senate Bill 1444, legislation which effectively eviscerates the TRS ActiveCare government health plan.

Independent Risk Management Services For Self-Funded Health & Welfare Plans

RiskManagers.us Service Schedule is flexible, allowing plan sponsors to pick and choose the level of service required.

Texas Backs Government Health Plan

By Bill Rusteberg

Texas recently gifted TRS ActiveCare $721,000,000 in additional funding ostensibly to cover claim losses for this +400,000 member government health plan in order to reman competitive. This cash infusion comes just at the right time as TRS ActiveCare is fighting to stay relevant since passage of Senate Bill 1444.

Battle of The Blues

Blue Cross of Texas is betting on Red & Black – they can’t lose. But wait! A Fifth Column arises funded by Blue Cross of Alabama…………

Healthcare at the Tipping Point

By Craig Lack

Everything in healthcare is undergoing change. Companies must also change — they must change the strategy, tactics and people involved in their decision-making process.

What Does This Have To Do With Insurance?

Doctors Revolt – Join DPC Movement

By Eric Bricker MD

The Story of Tryon Medical Partners shows us that if doctors don’t like the way a hospital is running their practice, they can leave and be successful.

Financial Planners To The Rescue

How Direct Pay Makes Health Benefits Affordable

By Jawad Arshad / ebn / October 03, 2022 / / Read Article

A direct-pay network can be set up to cover 85% to 90% of all medical events, which involve everyday acute primary care for both in-person and virtual visits, as well as diagnostics like labs and imaging, and pharmacies.

Republicans Abandon Obamacare Repeal

By Sahil Kapur / NBC News / Oct. 2, 2022 / / Read Article

Republicans are abandoning their long crusade to repeal the Affordable Care Act, making the 2022 election the first in more than a decade that won’t be fought over whether to protect or undo President Barack Obama’s signature achievement.

A Different Way To Fund Healthcare

OCTOBER 1, 2022 • ERIC L. REINER

When a Philadelphia law firm was facing a 12% increase in the cost of the health insurance it provided for its 55 employees and their dependents, it needed to explore other options.

How Artificial Intelligence is Transforming Insurance Underwriting  

The insurance industry is still largely reliant on manual processes, particularly when it comes to lines of business that use agents and brokers for distribution.  

Why Do The BUCAs Need Brokers?

Why do the big health insurance carriers need brokers? There are only four majors left in the market, Aetna, Blue Cross, Cigna and United Healthcare. All have fully operational account reps. eager to service business. Each has in-house sales reps to solicit new business. So why are independent brokers necessary? What value do they bring?

Reference Based Pricing – A Cash Cow for Hospitals?

Reference Based Pricing plans are increasingly becoming targets of hospitals seeking “found money” in desperate attempts at solvency instead of efficiency. RBP plan sponsors can expect a slew of demand letters for claims going back three to five years of “uncompensated care” to the tune of millions of dollars.