July 2023 – Risk Managers

Common Sense Health Plan

By Bill Rusteberg

Consumers are responsible for all cost of goods and services they purchase including health care services. Health insurance by definition is a reimbursement scheme for covered medical goods and services.

Don’t Blame Medicare for Rising Medical Bills, Blame Monopolies

For decades, hospitals have insisted that they charge the privately insured more to offset losses from Medicare patients. A health care regulator blows the whistle on that myth.

Sedera Health

Go here to see what your health insurance rates could be by adding common sense solutions to health care financing:

Aldeen’s Sunday Morning Bathroom Read

Public Service Announcement: Gag Clause Attestation Exercise

By Doug Aldeen, ERISA Health Attorney

A January 2022 BCBS of Texas ASO Agreement recently surfaced on the “internet.” Boy, I just realized that I sound like my father who knew how to keep a proper box score but I digress. A few thoughts:

They’re Coming For Your Records, Doc

By Darrell Pruit, DDS

Regardless whether you are a physician, dentist or optometrist, they are coming for your patients’ records……………………

Remdesivir – The Most Despised Drug In American History?

“The FDA can no longer be trusted with any drug under any circumstances. It’s all conflicts of interest.”

TSHBP: The Biggest Reinsurance Loss In Health Insurance History?

Reinsurance losses in excess of $60 million mount ten months into a 12 month contract on a level funded block of business for Texas school districts?

TRS ActiveCare Picks Up Killeen ISD

It’s hard for commercial carriers to compete against the Texas government health plan for Texas school districts when rates are lower due to government subsidies and a legislative mandate that requires annual rate caps of no more than 10%.

500,000 Texans Lose Medicaid

Hospital Administrator Reacts To The News

“Continuous Medicaid coverage ended in April. Many of the roughly half-million people stripped from the rolls don’t even know they’ve lost coverage yet.”

Ozempic – “I Wish I Never Touched It”

“I wish I never touched Ozempic. I wish I’d never heard of it in my life,’ she told CNN. This medicine made my life hell. So much hell.”

More Government Rules Drive Plan Sponsors Crazy With Mental Health Issues

Proposed rules include closing the loophole under the original enactment of the MHPAEA which did not require the health plans of state and local government employees to comply with the federal law.

The Good, Bad and Ugly of Litigation Financing

In insurance defense attorney Dennis Kass’ world, litigation financing firms lurk behind the scenes, pushing plaintiffs to undergo as much treatment as possible so lawyers can maximize the value of claims.

Knudsen v. MetLife Group – Excess Fee Health Plan Case

“A buzz is growing in ERISA legal circles as the Schlichter Bogard law firm sends LinkedIn solicitations asserting potential misconduct by the health plans sponsored by State Farm, Target, and other companies.”

Why Doctors Are Choosing Alternative Networks

Hospital At Home

Your patients can now have hospital-level care at home

Globally, more and more people accept and use digital healthcare. This helps to keep patients safer and it eases the burden on increasingly overwhelmed healthcare systems. This shift has highlighted the patient’s home as an important and relevant place to deliver healthcare.

BISD Releases Addendum To RFP

The Brownsville Independent School District posted a copy of their BCBS ASO Agreement to the public domain but removed it within hours of every Tom, Dick and Harry downloading it for posterity.

How to Contain Health Plan Costs with Group Captives

A group insurance captive is a strategic healthcare funding arrangement between multiple like-minded employers. Together, these employers can pool risk, leverage economies of scale, and create their own high-performing health plan.

The Fate of Private Practices

“The private practitioner is a dying breed.”

+100,000,000 Americans Qualify For Free or Discounted Hospital Care

More employers are wondering Why Pay For Health Insurance For Those That Don’t Need It?

It is estimated more than 100,000,000 Americans qualify for free or almost free hospital care thanks to IRC 501r. Here’s one example of a hospital’s Financial Assistance Policy.

Texas School Districts Experience Underwriting Miracle

Experience rating group health insurance is usually accurate most of the time within a margin of 5%. But that’s not always the case.

ClaimsBridge Partners With Highlight Health

ClaimsBridge and Highlight Health Announce Partnership to Deliver Unmatched Cost Containment Solutions

61 Texas School Districts Scrambling To Find Health Insurance? (Continued)

And now the rest of the story of 61 Texas School Districts Scrambling To Find Health Insurance?

61 Texas School Districts Scrambling To Find Health Insurance?

“Dozens of school districts that joined together to try to control health insurance costs for teachers are now having to figure out something new before next school year.”

Getting Things Done By Kicking Ass

This guy is definitely not in HR. He’s obviously in finance…………

The Kraft Heinz Lawsuit Against Aetna Is the ‘Tip of the Iceberg’

Give It To Me!

Kraft Heinz recently sued Aetna, claiming that the insurer is not providing all of Kraft Heinz’s medical claims data. More lawsuits of this sort are likely to come, experts warned.

Government Seeks To Strengthen Hospital Price Transparency Requirements………..

A Cuero, Texas based company’s self-funded group health insurance plan renews next month. Most of their employees use the local hospital in this one hospital town. Which carrier has the best prices at the town’s only hospital?

“A Health Plan Bold As Texas”

Curative Insurance Company, a leading health services company has launched a new employer-based $0 cost-sharing health plan in Texas…….

San Antonio Firm Supplies Over 10,000 Medications With Savings of 40-60%

“Apollo Vanguard’s mission is to help individual patients and self-insured employer health plans acquire the same prescription drug brands without compromising quality and affordability. Our group supplies over 10,000 medications including same brand prescriptions available in the United States with tremendous savings of between 40% to 60% lower cost.” – Armando Polanco

Pioneering the Price Rebellion: The Ten Commandments of RBP Adoption

Back in 2007 nay sayers predicted Reference Based Pricing would never work. BUCA reps and their hospital partners circled the wagons with dire warnings to plan sponsors with the threat plan members would not be able to access care.

Have Health Benefits Become A Huge Personal Liability For Employers?

Yes. And it’s worse than you think.

How To Count To Four

“J.J. Garza came out on camera talking about the money he received and how he would explain it if it ever came up.” – Javier Pena, Attorney

You can have 100% backing from administration but it takes four votes to get a school district contract. If administration has strong leadership you have a good chance of successfully counting to four. If administration leadership is weak you have an uphill battle unless you’re successful in doing something really stupid.

“The only way that we would be able to get into any school district was to be able to directly have a relationship with the decisionmakers — the school board, the trustees” – Josh Cerna, Convicted Felon

“It’s a common practice but it’s wrong” – Arnulfo C. Olivarez, Convicted Felon

AMPS Appoints New Chief Executive Officer

Advanced Medical Pricing Solutions Appoints Matt Brow as Chief Executive Officer and Board Member

MyHealthGuide Source: Advanced Medical Pricing Solutions (AMPS), 7/12/2023

Kirk Fallbacher to Continue as President of Drexi, Board Member and Member of the Leadership Team

PHOENIX — Advanced Medical Pricing Solutions (AMPS), a Cimmaron Healthcare Capital portfolio company focused on supporting self-insured employers and healthcare stakeholders in providing affordable, fair, and transparent medical and prescription benefits, announced the appointment of Matt Brow as Chief Executive Officer and Board Member.

Texas School Districts Struggle To Maintain Affordable Health Care

Region One 2023 School Finance & Operations Conference

Texas school districts are struggling to maintain affordable health care for their employees and their family members. Many districts are considering alternatives to TRS ActiveCare. Some have succeeded, while others have failed.

The Hidden System That Explains How Your Doctor Makes Referrals

“Losing patients to competitors is known as “leakage.” Hospitals, in response, use an array of strategies to encourage “keepage” within their systems, which in recent years have expanded their array of services.” – David Russo, D.O.

Fiduciary Liability Insurance

Fiduciary liability insurance is a type of insurance coverage that protects businesses and organizations from financial losses resulting from claims of breach of fiduciary duty, errors in plan administration, or other acts of negligence related to the management of employee benefit plans.

Lawyers To The Rescue! Exposing Egregious Practices In Health Care Finance Gains Momentum

Price fixing, working the spread, collusion and other nefarious activities driving up health care costs to the benefit of third party intermediaries is becoming an increasingly lucrative target for plaintiff attorneys.

Breaking South Texas Insurance News

Brokers working public sector groups in deep South Texas have found their work challenging.

Non-ERISA Groups Remain Fertile Ground For Insurance Brokers

New disclosure rules apply only to ERISA groups. That’s good news for conniving insurance brokers working public sector groups. Cities, counties and school districts are not governed by ERISA so it’s business as usual………………..

Sorry, We Changed Our Minds But I Can’t Tell You Why

The City of Harlingen issued a Request for Proposals for group health insurance. Now they have changed their minds. Why?

Who Do I Need to Sue to Get a Decent Cup of Coffee?

Who Do I Need to Sue to Get a Decent Cup of Coffee? Jittery Fiduciaries Consider Options as Health Plan Litigation Froths Up

By Ben Conley & Caroline Pieper on July 12, 2023

POSTED IN EMPLOYEE BENEFITS, FIDUCIARY GOVERNANCE, HEALTH & WELFARE PLANS, PLAN ADMINISTRATION LITIGATION

Seyfarth Synopsis: In light of a recent focus on price transparency, claims data, and hidden fees in the health plan world, employer-sponsored health plans have been bringing their fight to the courtroom in an effort to lower costs and demonstrate good fiduciary governance.

City of Harlingen Seeks Group Health Insurance Proposals

Notice is hereby given that the City of Harlingen, TX is requesting proposals for the following: RFP No. 2023-17 Employee Health Insurance FY 2024

How To Deal With An Insurance Broker “The Right Way”

“I don’t work for free. Neither do prostitutes. Most brokers, whether they realize it or not, are unpaid prostitutes working the streets picking up every unpaid opportunity that comes along.”

Independent Pharmacy Beats GoodRx Pricing

By Josh Butler

If you live in or near Amarillo, and you’d like to help your employees save on prescription drugs, and you’d like to see more healthcare dollars remain with local businesses, we’ve got a solution for you.

Learn How Employers Have Reduced Specialty Drug Spend By 100%

We receive hundreds of emails a week from industry sources. Today we received one under the subject banner “How employers can lower their specialty drug spend by 39% (or more).”

The Coming Tsunami of Excessive Fee Litigation

For some group health plan fiduciaries, there could be a storm brewing. Changes to the Employee Retirement Income Security Act of 1974 (“ERISA”), buried within the 5,593 pages of the Consolidated Appropriations Act, 2021 (“CAA”), create the possibility for a new set of potential plaintiffs in fiduciary litigation.

Selecting An Insurance Advisor

Selecting an insurance advisor is an important first step in managing a group medical program. Criteria usually revolve around several factors including compatibility. Corporate philosophies of the employer and insurance advisor should harmonize.

200 Employees Enjoy One Of The Best Health Plans On The Planet

By Adam Berkowitz, RHU

$2.7M in 3 years………………..That’s how much profit our health plan has generated for Schaefer Autobody Centers. At a 10x multiple, that’s massive value.

Connect Benefit

We are a concierge service that works with self-insured employer groups to help direct their members to our direct contracted providers. We keep costs down for employees as well as the employer by working with high-quality, transparent partners.

Aldeen’s Sunday Morning Bathroom Read

By Doug Aldeen
Editorial and Emerging Market Trend (Broker/Advisor Litigation/Voluntary Benefits):

Earlier this week, Heinz Corporation, through its fiduciary committee, sued Aetna alleging significant fiduciary violations. The proverbial dung hit the fan. Seismic? Hopefully. Seismic to me, however, would be adding the broker/advisor, Willis Towers Watson to the lawsuit.

RTP – The Future Of Health Care Finance

You’re at the grocery store. The cashier finishes ringing up the total. Instead of handing you a paper itemization memorializing the transaction, it is sent electronically into the nether world at the same time you insert your bank card into a machine linking the grocery store with someone else’s bank account. No copay needed. The bill is paid in full instantly. No balance billing. If the Food Stamp program can do this, why can’t your health plan?

Wild Atlantic Cod Fishermen Join Medical Supply Chain

Kerecis has developed and patented a technology platform based on intact fish skin from wild Atlantic cod, which is being used to treat burns and other complex acute and chronic wounds including diabetic, venous, trauma, and surgical wounds.

Little Known Legal Risk Is Gonna Be Well Known Faster Than A Speeding Bullet & More Powerful Than A Locomotive

This little-known legal risk could force big changes to our dysfunctional health-care system

Ruben Edelstein

By Bill Rusteberg

Ruben Edelstein practiced managed care in his own way. The son of immigrants, he ran a successful furniture business in South Texas. An astute businessman, he grew the business with locations throughout the Lower Rio Grande Valley in deep South Texas.

Magic Johnson’s Firm Powers New Long-Term Care Effort

“Magic” Johnson — an NBA Hall of Fame basketball legend — is helping an aging tech firm enter the long-term care benefits market.

Selling Sleepers

We Are Changing To Whatever Is Next

With their financial backs to the wall, surrounded by disgruntled workers who can’t afford the company’s health plan anymore, plus can’t afford to use it, more plan sponsors are leaping into shark infested waters while others are tip toeing through the tulips in search of alternatives.

Employer Lawsuits Heat Up Against Health Plan Administrators

“Is it not true your company has been stealing plan assets!”

July 6, 2023, 4:30 AM

Lawsuits by employers against insurers that administer employer health plans are beginning to mount, and workers could soon join the fray with litigation against employer-sponsored health plans.

Broker Responds To CFO’s Inquiry

Insurance Brokers Separating Straw From Chaff

I apologize for the late response as I was out of the country with limited access to emails. Free from internet bondage is refreshing, a good thing every once in a while. I recommend it!

Medical Errors May Result in More Than 200,000 Deaths

What do you call a medical student who graduated at the bottom of his class? (ANSWER: Doctor)

Telemedicine Company Flourishes In Hard Market

Dual purpose breath mint provides hope for the flaccid …………….

How Safe Is Your Hospital?

Article Referred By Chas Pierce

For more than 20 years, Leapfrog has inspired and led a movement uniting purchasers and patients to use transparency to improve the quality and safety of our health care system.

BCBSMN 2023-2024 Large Group Bonus Program

Put more money in your pocket by retaining and growing your business with the Blue Cross and Blue Shield of Minnesota large group bonus program.

Another Lawsuit Exposes BUCA Spread Pricing

by Chris Deacon

On the eve of Independence Day, I am conflicted as I share the news of yet another self-funded employer suing its TPA for breach of fiduciary duty.

Are FICA Reduction Programs Too Good To Be True?

“Have you been pitched a FICA-reduction program recently? If so, it’s a run-don’t-walk situation…….The programs are also marketed as no-cost to the employer, with the vendor being compensated by part of the FICA savings……..If these programs sound too good to be true, it’s because they are…..”

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