January 2023 – Risk Managers

Naw, I Want To Pay More Because I Like The Logo On My I.D. Card

Hiding Behind A Logo is a traditional American health care finance method of controlling the irrational correlation between cost of services and goods to end-user pricing while protecting ever increasing revenue streams from public display at the same time.

How a Drug Company Made $114 Billion by Gaming the U.S. Patent System

January 28, 2023

Barb Teron, a book buyer in Brook Park, Ohio, plans to delay her retirement because she is worried about Humira’s cost. Ms. Teron, who takes Humira for Crohn’s disease and colitis, has never had to pay more than $5 for a refill of the drug because her employer’s insurance plan picks up most of the tab. The cost, according to a pharmacy app on Ms. Teron’s phone, was $88,766 in the past year.

Amazing Statistics Gives Hope To Aging Insurance Brokers

1955 Insurance Salesman of The Year Still Plying His Trade in 2023

By Justin Nutt

A study in the U.S.A found that the most productive age in human life is between 60-70 years of age.

Virginia hospitals have to publish their prices. Would lawsuits compel them to obey?

By Eric Kolenich

Hospitals are now required by federal law to publish the prices of mammograms, CT scans and hundreds of other procedures.

Nosy Doctor Billed Medicare Over $46,000,000

Medicare pays through the nose for services rendered by frugal doctor……….

Proposed Legislation Says DPC Doctors Are Not Insurance Companies

“Daddy, who do you think you are, a doctor or an insurance company? Since insurance companies have always paid you and not your patients, doesn’t that mean you’re an agent of the insurance company?”

“Not any more son. Screw insurance companies! I work for my patients now” Dr. Doogood chortles.

Cash Pay Health Plans Catch Lawmakers Attention

Cash Pay Centric Health Plans are becoming a growing market trend, catching the attention of plan sponsors and government officials. The strategy is based on common sense, reason and logic applied to health care, something long missing from American health care financing.

The Power of Positive Thinking Didn’t Help Jack But He Never Gave Up…….

Jack Sullivan who murdered John Bradbury, a railroad officer, during a gun fight, is seen smoking a cigar a few moments before he took his last breath in the lethal gas execution chamber at the state prison on May 17, 1936 in Florence, Arizona. / AFP PHOTO / ACME / – (Photo credit should read -/AFP via Getty Images)

Theme Park Implements Large Waistline Risk Management Strategy

“It seemed like the theme park ride vehicles were getting smaller, and I was getting bigger…..”

Cash Pay Centric Health Plans Come of Age

By Bill Rusteberg

Years ago a hedge fund operator called seeking information on Reference Based Pricing, a nascent but growing market trend at the time. He continued calling over the next six months to which I was happy to share my experience, both good and bad, with Reference Based Pricing.

The Great Aldeeni Opines On RBP

Doug Aldeen takes a deep dive into Reference Based Pricing

JANUARY 23, 2023

Julianne calls up Doug Aldeen, ESQ an ERISA Healthcare Attorney and General Counsel to discuss the Reference Based Pricing (RBP) landscape, specifically how RBP has evolved over time.

J Patrick Rooney – Was He Right?

J Patrick Rooney is considered by many to be the Father of Margin Based Pricing better known these days as Reference Based Pricing. Many believe his conclusion of what the “sweet spot” reference point should be still holds true today.

Turbocharge Your Chargemaster!

Turbocharge your chargemaster then offer payers 50% off double the price………..

Cover Most Rx Needs For Only $5 / Month

Introducing RxPass from Amazon Pharmacy, a $5 prescription subscription that helps Prime members who take multiple medications save time and money

Off Label Use Of High Cost Drugs To Make Fat People Skinny Again

New Drugs for Weight Loss: What Plan Sponsors Need to Know

By Eileen O. Pincay, RPh

The latest generation of prescription drugs originally developed to help people manage their type 2 diabetes have been causing quite a stir for patients, health professionals and benefit plans, now that they’ve been approved and are being promoted to treat weight loss. Health benefit plan sponsors who are presently excluding weight-loss drugs from coverage are revisiting coverage rules because of the effectiveness and demand for these newer weight-loss drugs.

Centivo’s 2022 Healthcare Spend Analysis Reveals 21 to 33 Percent Cost Savings for Employers

Employees Using Centivo Also Visited Primary Care Physicians More and Experienced Fewer Emergency and Inpatient Visits Than Industry Benchmarks

BUFFALO, N.Y. — Centivo, a new type of health plan for self-funded employers anchored around leading providers of value-based care, today announced key findings from its 2022 healthcare spend analysis derived from the Company’s flagship Partnership Plan offering. The findings reveal dramatic healthcare cost savings for Centivo’s employer clients (21 to 33 percent) compared to widely recognized industry benchmarks.

School Is In Session This Friday – Make Sure You Don’t Miss It!

School is in session this Friday: Forward-looking #school leaders will join me in sharing the “secrets” to achieving world class healthcare while balancing their budget. Is your school district getting a passing grade on its #healthplan?

Health Rosetta Webinar For School Districts

This webinar will feature forward-looking school and union leaders who have followed the Health Rosetta blueprint to achieve the Quadruple Aim (better health outcomes, lower costs and better patient & clinician experience) and no longer needlessly squander money on healthcare. And how you can replicate these solutions.

Mercedes Independent School District Seeks Insurance Consultant

The last consultant quit, hence the RFP. That’s unfortunate because the previous consultant is widely considered among the best of the best in our industry.

Fee For Service Medicine

Ultimate Underwriting Tool

Underwriting High Risk Plan Members

“Your employer can ask you for a doctor’s note or other health information if they need the information for sick leave, workers’ compensation, wellness programs, or health insurance” – Uncle Sam

Libra

Since its establishment over four years ago, Libra has changed the face of the insurance industry in Israel and has led moves such as a revolution in car insurance with a shift to a kilometer-based pricing model, pet insurance with online claims payment, and more.

Huh? Says Rip Van Winkle

Proposed Texas HB711 Seeks To Eviscerate Managed Care Contracts

Managed Care Provider Relations Rep. Reacts To The News

“All-or-nothing clause”……….”Anti-steering clause”……….”Anti-tiering clause”……….”Gag clause”……….”Most favored nation clause”……….

Managing Risk vs Servicing Risk – The End of Status Quo Brokers?

With little formal training, a majority of health insurance brokers back in the day were simply spreadsheet artists………………………….

Blue Cross Settles Lawsuit for $2.6 Billion

Blue Cross settles lawsuit for about $2.67 billion……………………..

The Litigation

The process of the litigation was expensive as well as hard-fought. This is because it involved the creation of over 120 depositions, above 15 million pages, and more than a dozen pleas to dismiss claims of the plaintiffs. This is one of the unique kinds of an antitrust lawsuit and is said ‘historic’ in the court filing.

Educators Legal Liability

Educators Legal Liability Coverage (including employment practices)

Apex is a wholesale broker/program manager specializing in property & casualty insurance for public sector risks. We provide easy market access for local, independent agents to secure superior coverage at a competitive price.

Texas School District Facilitates Snitching

“Although we will not disclose your identity without your express permission, it is possible that your identity may be discovered during an investigation of the matter reported because of information you have provided“.

Alabama Man Secretly Helped Pay Strangers’ Prescriptions For Years

Tania Nix smiles with her father, Hody Childress

Residents say Geraldine, Alabama is as close to the fictional idyllic 1960s TV town of Mayberry as you can get in real life. Located about an hour outside of Huntsville, the town of less than a thousand is the kind of place where everyone knows their neighbour and most people watch the Friday night football game.

CMS Announces 600% Increase to No Surprises Act’s IDR Fee

“The nonrefundable administrative fee increased from $50 to $350. CMS says the case load of disputes is nearly ten times greater than initially estimated, resulting in the fee increase.

Continue reading CMS Announces 600% Increase to No Surprises Act’s IDR Fee

Jody Bright Explains What He Does For A Living

Jody Bright At Work Defeating The American Health Care Monster

By Jody Bright

In answer to a question posed by a fellow on his Facebook page, what we each do I replied the following:

How Much Do Health Insurance Brokers Make?

Where else in America can you make $1 million a year and play golf three times a week between vacations to Tahiti?

FreedomDocs

“Free At Last, Free At Last, God Almighty FREE AT LAST”

In 90 days, you could be seeing members of your new practice…………….

Cash Pay Option Can Be Added To Any Plan

Members decide between Free Care vs Not-So-Free Care at the Point of Service…………………….

Medical Stop-Loss Premiums Up Nearly 10% for 2022

Segal’s analysis shows that in 2022 the most common stop-loss insurance deductible is $250,000, up from $200,000 in 2021………….For a stop-loss coverage plan with a deductible of $200,000, the median monthly per-participant premium was $85.80 in 2022, Segal reported. For stop-loss coverage with a deductible of $500,000, the median per-participant premium was $29.90.

Are Self-Funded Health Plans Required To Cover Prescription Drugs?

Must self-insured plans provide essential health benefits?

Question: We understand that the Affordable Care Act (ACA) requires some health care plans to cover certain “essential health benefits.” Does that include our self-insured plan?

The Rapid Rise of The Leftovers

Crowded Waiting Rooms & The Rise of Direct Primary Care

“The percentage of U.S. physicians employed by hospitals, health systems or corporate entities grew from 62.2 percent in January 2019 to 73.9 percent as of January 2022.”

Skyward Specialty Announces Pricing of Upsized Initial Public Offering

Skyward Specialty is a rapidly growing specialty insurance company, delivering commercial property and casualty products and solutions on a non-admitted and admitted basis.

Bob Reim

All that we do on behalf of our clients is based upon these realizations:

1. If a loss is large enough, an insurance company will do everything possible to delay or avoid payment.

2. Claim adjusters and premium auditors work for the insurance companies – not for you. They aren’t your buddies. All ties, near ties or even questions go to the benefit of the insurance company.

3. a) Insurance companies and agents make money on what they sell; the more they sell, the more they make.
b) If they don’t have available the particular coverage you need, you may never know you need that insurance until you have a loss.

Pet Insurance Market to Touch USD 34.3 Billion by 2028 Thanks to Rising Companion Animal Population

January 11, 2023 / SkyQuest Technology Consulting Pvt. Ltd. / GLOBE NEWSWIRE / Yahoo / / Read Article

The pet insurance market was worth USD 7.1 billion by 2021 and is projected to reach USD 34.3 billion by 2028, with a high CAGR of 17.2% during the forecast period (2022-2028).

Celebrating 50 Years In Health Insurance

The Rise of Concierge Medicine

A concierge medicine practice, with revenues primarily based on annual membership subscriptions, thrives without the need to depend on reimbursements or expanded patient panels. Throughout its 20-year history the model has proven to be robust and resilient in the face of economic downturns, high inflation, sweeping healthcare reform initiatives, and most recently, the pandemic.

Medical Industrial Complex – Too Big To Fail

San Antonio’s Medical Industry Announces $37 Billion in Sales

More than 1 out of every 6 San Antonio-area workers are employed in health care, and about 50,000 net new jobs have been added in the last 10 years. Butler said the health care sector is easily the largest employer in San Antonio with 172,094 workers in 2015, a 13 percent increase from 2013.

Health Insurance For $10 Or Less

Affordable Care Act Marketplace enrollment jumps 18% over last year

The Department of Health and Human Services recently announced that there has been an 18% increase in Affordable Care Act health insurance enrollment over last year’s numbers, in a major victory for the Biden administration’s efforts to expand access to health insurance.

Colonoscopy Results Stuns Medical Community

Yet Another Stash Of Classified Documents Discovered During Biden’s Colonoscopy

WASHINGTON, D.C. — The White House is on edge this morning after investigators revealed a fourth stash of classified documents from Biden’s tenure as Vice President was found deep ………..At publishing time, doctors had confirmed the colonoscopy also turned up another hard drive linked to Hunter Biden.

Motorcycle Rallies Increase Organ Donations

US Motorcycle Rallies Increase Organ Donations

MyHealthGuide Source: David C. Cron, MD, MS; Christopher M. Worsham, MD; Joel T. Adler, MD, MPH; et al, 11/28/2022, JAMA Network

In this cross-sectional study of 10,798 organ donors and 35 329 recipients of these organs from a national transplant registry from 2005 to 2021, there were 21% more organ donors and 26% more transplant recipients per day during motorcycle rallies in regions near those rallies compared with the 4 weeks before and after the rallies.

Cameron Wants To Buy A TPA! Someone Please Help Him!

PAR Services Group Seeks to be a Family Home for a High-Quality TPA

MyHealthGuide Source: PAR Services Group, 1/13/2023

Nashville, TN – Cameron Dabir has formed PAR Services Group to acquire, grow, and permanently own a high-quality third party administration business.

When You Finally Get Health Insurance

Hospital Advertises Moral Hazard Strategy To Maximize Revenue

“In economics, a moral hazard is a situation where an economic actor has an incentive to increase its exposure to risk because it does not bear the full costs of that risk. Anytime a party in an agreement does not have to suffer the potential consequences of a risk, the likelihood of a moral hazard increases.”

Public Purchasing’s Worst Nightmare

Vendor complains of a “simplistic” bidding process that failed to delve deep enough, said its proposal got 303 out of a possible 310 points, but that the state asked “superficial yes-or-no answers” on those 310 questions, treated each question as equally important and refused to accept any explanations from bidders.

Will Individual Health Policies Replace Group Policies?

How Can A Group Health Plan Compete With This?

“It’s not fair!” says Johnny “The Group Guy” Jones. “Government subsidizes individual policies but not group policies? That’s gonna put me outa business!”

Hospital Stars In “I’ve Got A Secret”

Patients qualified for financial assistance; hospital sends them to debt collection instead

Nonprofit hospitals are required to provide financial assistance to low-income patients. Providence health system, however, did the opposite in many cases. Rather than ensuring that low-income patients received the financial assistance they were due, Providence hounded them to pay and sent debt collectors after them when they didn’t, according to a New York Times investigation. These actions were part of an official campaign to boost revenue called “Rev-Up” developed with help from corporate consultant McKinsey. The “Rev-Up” campaign directed employees to tell patients about financial assistance only as a last resort. The result: more than 55,000 patients were pursued by debt collectors when they should have been given a discount.

Primary Care Network Attracts 440,000,000 Registered Members

Value proposition: “Worry-free, time-saving and money-saving”, with the vision “to provide every enterprise with a harmonious workplace, every family with a dedicated doctor, and every user with a safe and healthy life”.

Persistent Insurance Salesman Lands Client – Now The Rest of The Story

Josh Butler Poll

State Extends Controversial Benefits Contract

Rewarding incompetence puts New Jersey in the lead for the 2023 World’s Dumbest Plan Sponsor Award. Their crowning achievement to date, reaching the world’s highest pinnacle of incompetence, is the case where a hospital billed $674,856 for a patient’s hospital stay, but the state’s health plan paid over $2 million to the provider instead.

Texas Considers HB 1840

Relating to the establishment of a bundled-pricing program to reduce certain health care costs in the state employees group benefits program.

Texas Legislature To Consider Shared Savings Strategy for Managed Care Plans

88(R) SB 358 – Introduced Version – Bill Text

Sec. 1276.054. SHARED SAVINGS PAYMENT. (a) Except as
	provided by Subsection (b), if an enrollee who requests a
	disclosure under Section 1276.052 elects and receives a health care
	service or supply the actual cost of which is less than the amount
	disclosed under Section 1276.052, the health benefit plan issuer or
	administrator shall pay to the enrollee 50 percent of the
	difference between the amount disclosed under Section 1276.052 and
	the actual cost, minus any applicable deductible, copayment, or
	coinsurance.

Texas Considers Risk Pool Funded By Federal Tax Dollars

Sec. 1511.0052. PURPOSE OF POOL. The purpose of the pool is
	to provide a reinsurance mechanism to:
	(1) meaningfully reduce health benefit plan premiums
	in the individual market by mitigating the impact of high-risk
	individuals on rates;
	(2) maximize available federal money to assist
	residents of this state to obtain guaranteed issue health benefit
	coverage without increasing the federal deficit; and
	(3) increase enrollment in guaranteed issue,
	individual market health benefit plans that provide benefits and
	coverage and cost-sharing protections against out-of-pocket costs
	comparable to and as comprehensive as health benefit plans that
	would be available without the pool.

Texas Legislature To Consider Diversity, Inclusion and Equity In Rate Making?

88(R) HB 1239 – Introduced version – Bill Text (texas.gov)

NEW BCBS MASSACHUSETTS HEALTHCARE MODEL: If You’re (Pick a color, gender, sexual preference) You Get Priority Over One Who Is (Pick a color, gender, sexual preference)

BCBS of Massachusetts announces first-in-state value-based contracts with incentives tied to equity

The plan says the move is the first in the state and among the first in the nation to create a financial payment model rewarding providers for eliminating racial and ethnic inequities in care.

Hospital Costs Haven’t Increased in Over A Decade So Why Is My Insurance Not Paying Attention?

Graph posted by Josh Butler on Linkedin

This graph tells you all you need to know about health care financing. There’s good money to be made working the spread (difference between the yellow line and blue line).

Why Am I Paying Brian A Commission?

By Bill Rusteberg

Over the weekend a storm blew through our place with high force winds causing roof damage. I placed a call to our local broker for assistance in filing a claim.

Small Rural Texas Hospital Publishes Price List

Cuero Community Hospital is Located In DeWitt County, Texas

Self-funded plan sponsors should conduct a study of local hospital pricing. Most haven’t. Why?

Generic Rx Drug Plans Gain Popularity

Martin Shkreli – Poster Child For High Costs Drugs

By Bill Rusteberg

Five years ago a small South Texas rural county, facing budget busting prescription drug costs for their employees, decided to take action. High cost prescription drugs were bankrupting their health plan.

Aldeen’s Sunday Morning Bathroom Read (Mad Lib Edition)

By Doug Aldeen

The five most powerful phrases in healthcare are (fill in the blank):

International Captive Exchange, A Health In Tech Company, Becomes Managing General Underwriter (MGU) for Liberty Mutual Insurance Company

Published: Jan. 6, 2023 at 7:00 AM CST

STUART, Fla., Jan. 6, 2023 /PRNewswire/ — International Captive Exchange, LLC (ICE), a Health In Tech, Inc. company, an industry-leading Insurtech company that delivers disruptive innovation and proprietary technology, has entered into an agreement to serve as the Managing General Underwriting for a program providing employer stop-loss insurance. Under the agreement, ICE will solicit, underwrite, bind, and issue such policies on behalf of Liberty Mutual Insurance company.

Quote Your Group in as Few as Two Minutes!

What took days now takes 2 minutes. Lunch in New York, dinner in London. Instant mail vs snail mail. Next thing you know an employer sponsored health insurance sales cycle will reduce from months or years to hours or minutes at the snap of a finger…………