Blue Cross Tells Client To Stick It

Suit Against Anthem Exposes Conflict Over Health Claims Data

Article Referred By C. Smith, M.D.

An employee health plan sues its health insurance administrator for refusing to turn over claims data that would allow the employer to verify the accuracy of charges against its self-funded health insurance plan. Medical supply vendor Owens & Minor says Anthem Blue Cross and Blue Shield has refused to provide it with claims data since 2021 as required by federal law. Anthem says its claims data involves proprietary arrangements that it doesn’t want to make public. Several similar lawsuits have been settled out of court, with details hidden behind non-disclosure agreements.

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Aldeen’s Sunday Morning Bathroom Read

Doug Aldeen• ERISA Healthcare Attorney and General Counsel

The state of Connecticut plans to erase $2 billion in medical debt for its residents.
Caveat Emptor and Key Inquiries: 1) Determine the original price of the medical services and 2) How many individuals were otherwise eligible for financial assistance? Perhaps $20mm is still overpaying these hospitals…

“No one wakes up and says, ‘I want to go to the hospital,'” said Ayesha Clarke, interim director of the Hartford-based nonprofit Health Equity Solutions. “However, when it happens, seeking care should not result in a lifetime of financial hardship.

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Did You Read The Contract? Then Why Did You Sign It?

It’s been our experience over the years most Plan Sponsors never read their TPA administrative agreements. As an example, some years ago a client approved their ASO agreement without first allowing us to review it as was required under our management agreement. They screwed themselves and I had to tell them they screwed themselves. Sugar coating has never been our style.

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Humana to Exit Employer Group Commercial Medical Products Business

Article Referred By Dan Meylan

LOUISVILLE, Ky.–(BUSINESS WIRE)– Humana Inc. (NYSE: HUM) today announced that it will be exiting the Employer Group Commercial Medical Products business, which includes all fully insured, self-funded and Federal Employee Health Benefit medical plans, as well as associated wellness and rewards programs.

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Is A “Cash Pay Revolution” Coming For Hospitals?

“The market is going there,” said Larry Van Horn, associate professor of management, law, and health policy and executive director of health affairs at Vanderbilt University. “You’ve got direct primary care, you’ve got physicians going and moving into cash pay. You’re gonna have to sit there at some point and say, ‘Wait a minute, they’re taking my business.'”

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TRS ActiveCare Premiums Underfund Claims

TRS ActiveCare Actuary Under The Gun

Will the state continue to make up the shortfall for the TRS ActiveCare government health plan? Commercial carriers operating in the real world competing for Texas school business don’t enjoy that advantage. So how can the commercial carriers and third party administers compete? Sneaky underwriting?

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TRS ActiveCare To Consider Change In PBM Tomorrow

TEACHER RETIREMENT SYSTEM OF TEXAS MEETING BOARD OF TRUSTEES

AGENDA February 16, 2023 – 12:00 p.m.

Discuss and consider selecting a pharmacy benefit administrator(s) (PBMs) to improve and enhance financial performance and services for public education employers, employees, retirees, and their families participating in the TRS-Care Standard, TRS-Care Part D (solicited as TRS-Care Indirect EGWP with Wrap PDPs), and TRS-ActiveCare……..

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Hospitals Will Be Insurer of Last Resort For 33% Of Oklahomans

The following article describes the plight of one third of the population of Oklahoma who are on target to lose their Medicaid health insurance this year. The article does not mention 100% of those affected by the Medicaid cut will qualify for free hospital care under IRC 501r…………….and guess who is going to pay for all of this……………

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Helping Physicians Can Get It Right The First Time

Bridges, 80, becomes 1st Doctorate of Health Informatics graduate at UTHealth School of Biomedical Informatics

Article Referred By Brent Evans – Sundown, Texas

West Texans are fiercely independent. There’s nothing a West Texan can’t figure out. When something breaks they don’t call for help, they fix it themselves. If they don’t know how, they figure it out. This fellow is no exception.

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Four School Districts Win Case Against Hospital System – “You Can’t Have Your Cake & Eat It Too”

Aldeen’s Weekly SUNDAY MORNING BATHROOM READ

Pottstown’s superintendent Stephen Rodriguez said he was thrilled by the decision. “This decision is validation that our concerns with Tower Health were appropriate. They did not meet the measure of the law and should be paying their fair share of taxes and I look forward to them paying up.”

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Professional Governmental Underwriters LLC

Professional Governmental Underwriters, Inc. is a full-service risk management company dedicated to assisting public, educational and non-profit entities in the management of their professional liability exposures.  Current operations are dedicated to underwriting and marketing Public Officials Liability, Law Enforcement Liability and Educators Liability insurance.

We are dedicated to providing state-of-the-art professional underwriting management and loss control advisory services on behalf of our designated carriers. We operate through a network of professional producers who seek specialized services for their public, educational and non-profit entity clients.

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RBP Direct Hospital Agreements – Be Careful of What You Hope For

By Bill Rusteberg

A self-funded plan sponsor has direct agreements with several San Antonio hospital systems. These direct agreements are a straight, flat rated Medicare based fee schedule without the usual managed care outliers such as escalator clauses, stop loss provisions, etc.

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Non-Profit Hospitals Want Their Cake & Eat It Too

Montana’s Tax-Exempt Hospitals Oppose Increased Oversight by State Officials

More than half of acute care hospitals in the United States are nonprofit hospitals, which must record community benefits — such as covering a patient’s bill or offering mental health services at a loss — with the IRS for their tax exemptions. But federal rules around how hospitals tally charitable acts are broad, with oversight lacking. Pressure for more transparency has mounted as about 6 in 10 adults in the U.S. with household incomes below $40,000 have medical debt, and altogether Americans owe an estimated $195 billion or more.

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The Defense Collaborative

Headquartered in St. Louis, Missouri, The Defense Collaborative is a fresh take on risk / claims / liability / insurance / defense. It is a collaborative networking and education platform facilitating the creation of relationships through networking events, CLE/CE approved seminars and non-CLE/CE approved seminars. Fun culture. Safe environment to gain feedback. No gains other than to facilitate meaningful connections through education/scenarios.

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Blue Cross Discloses Negotiated Rates With In-Network Providers

The Transparency in Coverage Final Rule and Texas House Bill 2090 require disclosure of the negotiated rates with in-network providers and the historic allowed amounts paid to out-of-network providers, for all health plans available to employers.  Files containing this information for the plans covered are published on this page.

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Brownsville ISD Trustees Debate The Value Of Their Health Insurance Broker

Brownsville ISD board members debate the value of their health insurance broker at a Brownsville ISD Insurance Committee Workshop on May 13, 2020.

There is a difference between managing risk and servicing risk. Legacy health insurance brokers provide the later. New era health insurance brokers provide the former leaving TPA’s to service the risk.

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Government’s Two Step Solution To Solving Health Care

“The best way to control costs is to pay for them'”

(1) Crank up the printing presses and gift more money to health insurance companies to pay for out of control health care costs and (2) Gift stolen wages from working class Hyphenated-Americans to health insurance companies to pay for out of control health care costs.

“Bill provisions include making enhanced subsidies (OTHER PEOPLE’S MONEY) for Affordable Care Act Health Insurance Marketplace coverage, extended through 2025 in the Inflation Reduction Act, permanent; designating the second-lowest-cost Gold plan the benchmark plan upon which premium subsidies (OTHER PEOPLE’S MONEY) are based; and increasing the value of cost-sharing reduction (CSR) assistance for those with income between 100 and 250 percent of FPL (Federal Poverty Level) while expanding eligibility for CSR assistance to people with income up to 400 percent of FPL.”

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