March 2023 – Risk Managers

How Much “Juice” Can You Squeeze From A Patient?

Answer: Not enough

School District’s Health Insurance Up 245% But They Get A Hell of A Deal on Fixed Costs?

Is Blue Cross paying ECISD for the privilege of being their TPA?

Today’s Pop Quiz

Which is the easier sale in today’s health insurance brokerage market?

A Common Sense Health Plan That’s So Good It’s Hard To Sell

Have you ever tried selling something that’s so good it doesn’t sell? “It’s too good to be true!” says the prospect. “If it were as good as it is, everyone would be buying it. Since no one I know is, it must not be as good as you’ve proven it is!

Texas Hospital Association Cries A River

SOURCE: Darren Fogarty – Associate Director, Purchaser Value at PBGH

5 days ago, the Texas Hospital Association issued a “fact” sheet that lies by omission in citing $3.2 billion in losses for Texas hospitals with nary a mention of where those losses came from.

Pfizer and Moderna Enter “Price Gouging” Phase?

Psssst! Godfather, Michael Says We Need To Get Into Pharmaceuticals!

For the two calendar years covering the roll-out of its toxic C19 mRNA injections, Moderna had sales of 37.5 billion bucks that cost it 8.6 billion bucks to make – leaving gross margin of around 29 billion bucks.

Specialty Drug Cost Containment Strategy – The Indian Giver Method

Why would any payer cover something when they have only the slightest intention of doing so?

Texas SB 1296 – Bureaucrats Have Information You Will Never See

Have you ever been told as a kid you couldn’t have something?

Texas Legislature Moves to Discontinue Work Comp Group Self-Insurance

Texas lawmakers proposed a bill that would discontinue group self-insurance and dissolve the Texas Self Insurance Group Guaranty Fund and Trust Fund. Identical companion measures HB 4859 and SB 2269 would prohibit the commissioner from issuing a certification of approval to a proposed self-insurance group on or after Sept. 1.

Continue reading Texas Legislature Moves to Discontinue Work Comp Group Self-Insurance

BUCA Bucks vs MedSave Bucks

Every self-funded plan maintains a money pot to pay claims as they occur. Monies leaving the pot are often paid in BUCA Bucks.

Monster Texas School District Gets An “F” In Health Care Finance

The second largest employer group south of San Antonio tackles rising health insurance costs the old fashion way………………..

Drug Dealer Advertises “Everyday Low Price of $389,106”

There’s not too many plan sponsors that can afford a plan member’s $389,106.02 drug habit. It only takes a few specialty drugs like this to bankrupt a group medical plan.

Insurance To Credit Cash Pay Patients Under Proposed Texas Legislation

If proposed HB 2002 passes the Texas legislature this session, “An insurer shall credit towards the insured’s deductible and annual maximum out-of-pocket expenses an amount the insured pays directly to any physician or health care provider for a covered medical or health care service or supply if a claim for the service or supply is not submitted to the insurer”.

Texas Legislature Eyes Primary Care Expansion Through FQHC’s

A bill has been introduced in the Texas legislature intended to expand primary care health services to employees of participating employers…………….

Why Employers Change Insurance Brokers and Benefits Consultants

EMPLOYER GUARD DOG vs CARRIER LAP DOG?

A Common Sense Health Plan Option You’ve Never Heard Of………..

The BUCAs and their brokers won’t tell you about it because it goes against their business model…….

Billed Charge = $17,462.66, Cash Price = $449

Insurance company shows bogus discount designed to convince consumer their worth (Thank God I had insurance!). Consumer on the hook for the balance, or +$2,000 (Not bad, I could have been on the hook for +$17,000 without insurance!). Cash price is less than $500 (that’s still too much). This kind of bullshit happens every day………………..

PBMs Under Attack In Congress

Setting Aside Reserves

By Bill Rusteberg

Plan sponsors new to self-funding invariably ask “How much do I need to set aside for reserves upfront?” The answer is you don’t. Instead you fund 18% of your expected liability, or 1/12 x 2.25 during the first three months of the new plan.

BUCA Brokerage Monopoly Tough To Beat

Independent TPA’s, especially with those with out-of-the-box solutions, are second class citizens scrabbling for business in the insurance brokerage community.……..

It’s Coming! States Eye Hospital Price Controls As Best Health Care Fix

Hospital price caps gain traction among state governments as a means to lower health care costs………..

Another Golden Nugget From The Godfather of IRC 501r

SOURCE: Doug Aldeen, Attorney At Law & Godfather of IRC 501r

The Texas Hospital District statute takes charity care one step further: Texas places the burden ON THE FACILITY to establish the ability of the patient to pay at cost.

Nurse Navigators Rock!

By Deb Ault

Patient calls the AIMM nurse because she is in the ER. This doesn’t require precertification but the nurse asks a few questions about what landed her in the ER. She begins to tell the nurse that they want to admit her, but they don’t have any beds. They told her that she would have to be admitted in order to get an MRI because they “don’t do those for ER visits”. They told her that if they can’t find a bed for her, they would have to transport her to a different hospital via ambulance to have the MRI done and be admitted.

Interlocal Purchasing Cooperative

Recognizing that local governments engage in a wide array of cooperative efforts with each other in the purchase of goods and services as a method to reduce duplication, offer economies of scale, and generally improve governmental efficiency, RISKMANGERS Agency was created by participating local governments sharing these common goals.

RISKMANAGERS Agency is an administrative agency created by the participating local government Members as authorized by Section 791.013 of the Texas Government Code to supervise the performance of an interlocal contract.

Indiana’s Hospital Systems Stand Committed to Affordability

“The market is working, and we should let it continue……………………….”

A Rx Business Strategy That’s Guaranteed To Produce Huge Profits

Imagine a red hot market demand for weight reducing drugs under patent costing north of $12,000 per year with a lifetime dependency, prescribed by physicians and paid for with other people’s money.

New Age Captive Opportunity

Medical Stop Loss Captives are a growing market phenomenon catching the attention of small to medium size plan sponsors. A Captive can be structured to meet the specific needs and goals of like minded member employers.

Ohio Firm Saves $37,000,000 In Medical Bills

CLEVELAND — aequum LLC, acting on behalf of 400 self-insured health plans and their participants, announces a noteworthy two-year milestone of successfully resolving over 10,000 claims for more than 5,000 member patients, saving over $37 million of disputed charges and earning recognition throughout the self-insured community.

Millennials’ Take On Health Care

SOURCE: Survey: 62% of Millennials Would Put Pet’s Health Before Their Own (prnewswire.com)

Seventy nine percent of millennials say they ask “Dr. Google” about an ailment before making an appointment to see an actual doctor. Almost half (45%) are more likely to try telemedicine before visiting a doctor’s office.

Oh Oh, What Do We Do Now!

Now that you know, and they know, you’re screwing your employees it’s time to understand that, whether you like it or not, you’re in the health insurance business. Poor oversight and bad decisions will not stand anymore……………….

The Upside Down Hospital

Description	Associated Codes	Gross Charge	Payer Allowed Amount	Cash Discount Price	Deidentified Min Allowed	DeIdentified Max Allowed
Description	Associated Codes	Gross Charge	Payer Allowed Amount	Cash Discount Price	Deidentified Min Allowed	DeIdentified Max Allowed
Bypass Graft Of Blocked Heart Artery	231-236	$122,450.30	$47,573.58	$85,715.21	$21,431.63	$62,562.13
Bypass Graft Of Blocked Heart Artery	231-236	$122,450.30	$32,572.65	$85,715.21	$21,431.63	$62,562.13

You would think a hospital would give a better price for cash than they would for insurance companies. No claims to file, no chasing patient share, immediate cash payment, no precertification bullshit, no concurrent care review protocols to mess with, no prolonged verification of benefits phone calls, etc.

Insurance vs Cash Pay for Health Care?

Insurance companies provide the illusion that by using their in-network providers you will save money.,,,,,,,,,,,,,,,,,,,,,,,,,

Pratter Logic

Earning <$58,320 = Free Health Care

58% of Americans earning less than 400% of the Federal Poverty Level qualify for free health care. Most plan sponsors have failed to recognize the impact this would have on their second most expensive business expense after salaries if they would simply transfer risk through IRC 501r hospital financial assistance policies.

Texas Legislature Ends Hospital Bullshit

100% bipartisan support punishes hospitals in a meaningful way who don’t publish their prices for all to see…………

No Gag Rule Opens Doors For Inquisitive Minds

Does your TPA ASO Agreement include limited audit rights? If so your plan may be non-compliant with the new No Gag Rule for group health plans.

New Rx Cost Driver – Off Label Drug Treatment for Obesity

A $900 per month drug with a $25 co-pay seems like a great buy for plan members fighting obesity. But it only takes a few plan members to drive up a plan’s drug spend to budget busting levels………..

North Korea Unveils New Wellness Program

The 단고기료리전문식당 is part of leader Kim’s efforts to improve people’s diets………………

American Health Care Has A Moral Problem

By Marshall Allen

I recently reviewed the bills of a woman whose insurance plan had negotiated a price for her and her health plan to pay $5,805 for an emergency room visit.

Ava Ortiz Wins Houston Rodeo’s “Mutton Bustin” Contest – Qualifies For Final Championship Event

Ava Ortiz, age 6, gave an impressive performance this evening at the Houston Rodeo’s Mutton Bustin event.

Buyer’s Remorse In Contract Disputes

“Some protest or grumbling with an acceptance does not invalidate the agreement…….”

Let’s Go Shopping………….For Health Care

All industries compete on price and efficiency, but the healthcare industry exists to maximize billings and revenue.

Is American Hospital Billing The Biggest Scam Today?

“Sadly, healthcare in the U.S. has become dominated by third-party payers. This means that the government – through public insurance programs like Medicaid and Medicare – along with employers and insurance companies, pay most of the bills to hospitals and other healthcare providers. They pass this cost along to patients and taxpayers, of course, through higher insurance premiums and higher taxes, but this means there’s no downward pressure on price, and little leverage (absent government action) for price transparency”

Removing The Third Person In The Room

Removing the third person from the room is every physician’s dream. For DPC doctors the dream has become true.

Sex Sells – Winning Sales Quota by Banging Doctors

In 2012, Insys hired a new sales executive: Sunrise Lee, a Florida escort service manager and former strip club dancer with no academic degree, according to Guzman’s complaint. Burlakoff allegedly defended the decision, claiming, “Doctors really enjoyed spending time with her and found Sunrise to be a great listener.” He added, “She’s more of a closer.”

Schuessler’s Solution To Solve Health Care Actually Works!

One critical Benchmark for a healthplan is Medical Expense Per Employee Per Year (PEPY). Our #FairCostHealthPlan is $4,428 PEPY while the national average is $12,125 (Truven Medstat) – 64% below the nat’l average.

How Employers Can Achieve a Fair Price in Hospital Negotiations

**J Patrick Rooney – His research shows Medicare Plus 25% is the reasonable amount for hospitals to charge……**

“Why should a plan sponsor negotiate a hospital contract when plan members do that already?” Bill Rusteberg

Eli Lilly Slashes Insulin Costs by 70%

Eli Lilly is slashing prices on its most-prescribed insulins and capping out-of-pocket costs for patients amid pressure from consumers and the Biden administration. After years of price hikes on insulin, Lilly on Wednesday said people with diabetes would see 70% reductions on its most common versions.

$10,000 Dental Plan

National Care Dental offers PPO plans underwritten by Met Life and Nationwide under one contract. You will have a unique enrollment portal and network for each carrier, however a shared back office to view your book of business and commissions. Great brand names to promote!

The “Magical Mathematical Pencil” Method Of Solving Health Care

Employees Earn $4,128 Pay Raise Plus Free or Almost Free Health Insurance……..

Mueller Manufacturing Company decided there was a better way to provide their 300 employees with free or almost free health insurance while gifting them a raise at the same time.