September 2023 – Risk Managers

Do It Yourself Benefit System: Health In Tech’s Quoting Platform

Tall Tree Administrators will leverage Health In Tech’s eDIYBS (Enhanced Do It Yourself Benefit Systems) platform, known for its speed and efficiency in underwriting and plan quoting.

AMS CensusRater

AMS re-release of CensusRater, an automated risk module that uses census data to project small group risk.

TPAC powered by SLEQ™: When you need a Stop-Loss quote right now

Faster Than A Speeding Bullet, More Powerful Than A Locomotive

New Age underwriting methods binding coverage for group health plans quickly and efficiently makes life easier and less frustrating for brokers, TPA’s and plan sponsors.

Health Care Consumer Misconception: Higher Cost = Higher Quality

Branding is Everything in Consumerism

“My doctor is the most expensive doctor in town because he’s considered the best in his specialty. And he only charges me my $1,000 deductible!”

Great Talk By Adam Russo at HealthRosetta Event

A Blank Slate: Identifying the Foundational Pillars of What the Perfect Plan Design Should Be – Adam Russo, The Phia Group on Vimeo

Legislation Proposed To Expand DPC Access To HSA’s

“The legislation would clarify provisions of the Internal Revenue Code to remove barriers for individuals with Health Savings Accounts (HSAs) from using those funds to access DPC, a health care delivery model which provides high-quality care at lower cost for individuals of all ages and incomes across America.”

Which Door Is Your Consultant Recommending?

Plan sponsors pay insurance brokers and consultants big bucks to save them money on health care spend.

Will Obesity Drugs Break the Healthcare System?

By Dutch Rojas

Novo Nordisk and Eli Lilly are about to start raking in tens of billions of dollars a year on their new obesity drugs, say Wall Street analysts. That’s great news for the drug makers, certainly, but it could be a disaster for the companies and government agencies set to pick up the bill.

5 Reasons ICHRAs Could Be An Alternative To Self-funding

SOURCE: 5 reasons ICHRAs could be a an alternative to self-funding | BenefitsPRO

Transitioning a company to a self-funded model isn’t always a silver bullet for employers in the long run. For many organizations, an individual coverage health reimbursement arrangement (ICHRA) is the better solution.

Hiding Fixed Costs On The Claim Side Of The Ledger

Posted By Rina Tikia On Linkedin

“Evidence included correspondence showing Aetna literally told Optum to “bury” its fees by using a dummy code, and that Optum helped Aetna “scout” for a usable dummy code……”

Aldeen’s Sunday Morning Bathroom Read – Credit Report Edition

Removing Medical Bills From Credit Reports – A RBP Game Changer…………

Market Impact: Reference based pricing and cash models become ubiquitous (plus direct contracting) and unless it is Mother Theresa calling every five minutes, I am not answering the phone…

CADAVERIC DONOR TRANSPLANT AGREEMENT

Surgeons Take Inventory – Auctioneer Paces Patiently Before Festive Audience As Hopeful Family Members Look On In Silent Anticipation. Will Little Johnny Finally Get His Bass Boat?

10,000 Pound Gorilla Sees No Value In DPC or Cash Pay Claim Strategies

Trustees give up free babies & other weird things…………..

The Brownsville Independent School District, the largest employer south of San Antonio with more than 10,000 member lives eligible for coverage under the district’s health plan, voted last night to change the logo on their health insurance program as a cost savings measure.

The Truth About Statins

America’s Most Popular Drug Has a Puzzling Side Effect. We Finally Know Why.

Watch How To Sell A $55,000,000 Contract In 5 Minutes

Speed closing a $55,000,000 sale faster than a melting raspa on a hot September afternoon in Deep South Texas will be on full public display tomorrow at a special meeting of the Brownsville Independent School District. Rumors have it vendors are scrambling to be the first to retain John Moschitta as their spokesman to gain a competitive advantage. In the alternative presenters are studying the Helix DNA presentation of 1953.

Danish Company Owns Rights To Ozempic & Wegovy

Novo Nordisk manufactures and markets semaglutide, used to treat diabetes under the brand name Ozempic and obesity under the brand name Wegovy.

Cigna and its Terrible, Horrible, No Good, Very Bad Position on [NOT] Filing Attestations of Compliance on Behalf of Fully Insured Plan Clients

By Julie Selesnick – Senior Counsel at Berger Montague

Since December 31 and the first attestation requirement for group health plans is fast approaching, I decided to take a look at how the major insurance carriers providing administrative services to self-funded plans are “helping” the plans with this requirement. I figured I would look at each of the larger carriers and report back to the benefits community on LinkedIn about how they were handling it.

Underwriter Gushes Over Government Cash Pay Health Plan

Medical procedure cost him $150,262.87 while his benefit earned is $1,314.35 producing a loss ratio of 0.0087……………….

Kohlberg Kravis Roberts & Co. LP To Invest +$1 Billion in USI

USI Insurance Services LLC on Monday said that existing shareholder private-equity firm Kohlberg Kravis Roberts & Co. LP is making a new equity investment of more than $1 billion in USI and will become its largest shareholder.

National Casualty Co. v. Georgia School Board Association – Risk Management Fund

“When two insurance contracts both provide only excess coverage, liability must be determined on a proportional basis………..”

Insurance Issues Making Popular Obesity Help Hard To Get

Doctors and patients say many insurers have stopped covering Ozempic and Mounjaro outside their approved use for diabetes. Some insurers and employers don’t pay for Wegovy.

What Is the Difference Between the UB-92 and HCFA-1500 Forms?

The primary difference between the two forms is related to who uses them – medical facilities (UB-92) vs individual practitioners (HCFA-1500).

Aldeen’s Sunday Morning Bathroom Read

North Carolina State Treasurer Dale Folwell (and friend) recently published the attached Price Transparency and “Markup” Analysis of North Carolina hospitals: NC hospitals are jacking up prices and lack transparency, says report | Charlotte Observer

TrueScripts Launches PriceProtector+, Powered by GoodRx To Help Lower Out-of-Pocket Drug Costs

How Sweet It Is!

MyHealthGuide Source: TrueScripts, 9/13/2023

TrueScripts Management Services, a pharmacist-founded Prescription Benefit Management (PBM) company, announces the launch of a new program designed to seamlessly deliver savings on generic prescription medications.

Firm Quotes In 2 Minutes

Within an impressive 2-minute turnaround time, eDIYBS generates a comprehensive firm proposal quote featuring 12 plans and four tiers. Its distinguishing feature is the unparalleled control it grants users over underwriting guidelines, network discounts, and personalized plan designs.

Do Specialty Drugs Pay Commissions?

In a previous post on this blog we asked our three readers “Do you know, or have any idea, what the commissions (rebates) are on Skyrizi: 1 Ml Risankizumab Rzaa 150 Mg/Ml Auto Injector?”

Question For My Friends On Linkedin And Beyond

Do you know, or have any idea, what the commissions (rebates) are on Skyrizi: 1 Ml Risankizumab Rzaa 150 Mg/Ml Auto Injector?

A CLAIM IS A CLAIM IS A CLAIM

By James Farley – President at J.P. Farley Corporation

The above statement is a pretty commonly held of plan sponsors, many broker/advisers, and the public in general. It is a misconception.

Non-Profit Hospital Pays CEO $7.7 Million, More Than Spent On Charity Care In 3 Years

Children’s Hospital of Philadelphia CEO Madeline Bell was paid $7.7 million in 2021, making her the top earner among CEOs of the Philadelphia region’s nonprofit health systems. Read more Anton Klusener/ Staff illustration. Photos: The Inquirer, Getty Images

“What’s at stake is easy to see, Freiwald said: “It’s real money to these school districts, which is to say to my kids, your kids, our kids, the community of our children growing up in underfunded school districts, while beyond-wealthy hospital corporations are keeping their property-tax dollars in their own pockets.”

Paid Family Leave Insurance

Texas’ insurance code now includes voluntary Paid Family Leave as a new form of insurance.

Transferring Risk To The Individual Market

PROBLEM:

PLAN SPONSOR HAS A HIGH RISK INDIVIDUAL WITHIN THEIR HEALTH PLAN WHO HAS BEEN LASERED BY AN UNBUDGETABLE AMOUNT ($350,000) PLACING THE PLAN SPONSOR’S HEALTH PLAN AT RISK.

Hospital Solution To Patient Debt

Secure Patient Revenue

Secure 100% of known and unknown patient responsibility at Time Of Service.

Aflac First To Provide Voluntary Paid Family Leave Insurance in Virginia

12 Sep, 2023, 08:00 ET SOURCE: Aflac is the first insurance carrier approved to provide voluntary paid family leave insurance in Virginia (prnewswire.com)

EMPLOYER RE

Employer to Employer Risk Transfer

Plan eliminates specialty drugs. The employer down the street doesn’t. Joe Sixpack needs a $500,000 specialty drug.

Company Hires New Risk Management Consultant

Univ. of Tex. M.D. Anderson Cancer Ctr. v. McKenzie

M.D. Anderson Loses Governmental Immunity – Texas Tort Claims Act (“TTCA”). The Texas Tort Claims Act (TTCA or Act) is a set of state statutes that determine when a city or other governmental entity may be liable for accidents or intentional acts that cause property damage or personal injury.

In this medical malpractice case, the family of a patient who died after participating in a clinical trial at the University of Texas M.D. Anderson Cancer Center (“MDACC”) alleges that the patient died because of MDACC’s negligence.

+32,000 Texans Work For United HealthCare

Committed to our Texas community

UnitedHealthcare is dedicated to supporting Texas employers, employees and their families by building strong, lasting relationships in the community.

Employers See Tremendous Savings As High Dollar Claims Leave Their Plan

Patient dumping or smart risk management? Are lasers relevant anymore? The HOT POTATO risk transfer method……………….

Quest To Live Forever Includes Full Body MRIs

Silicon Valley’s quest to live forever now includes $2,500 full-body MRIs

Proponents of Prenuvo scans argue that they should become as routine as a mammogram or colonoscopy. Celebrities and venture capitalists are flocking to a growing number of clinics — and flooding social media with chic scan pics.

11 Best Hospitals In Texas For Orthopedic Surgery

Patsy Newitt – Friday, September 8th, 2023

Healthgrades named the top hospitals for orthopedic surgery in 2023, including 11 hospitals in Texas.

Meet The US’ Oldest Healthcare Billionaire

Started company with $720…………………

Brownsville ISD To Discuss Health Insurance During Sept. 18 Special Meeting

Stock up on popcorn and clear your calendar for an action packed live stream event you won’t want to miss……………….

Texas Says Goodbye To Most Favored Nation Clause

Managed care network Contracting: Prohibits the following provisions in network provider contracts:

No Sir! Read Our Agreement!

Next time you’re asked to sign papers at the doctor’s office or hospital, documents that no one ever reads, try signing your name “I did not Read this” or “I Don’t Agree With This.”

The Shrinking Number of Primary Care Physicians

“I couldn’t stand it,” he said. “It wasn’t how I was taught to practice”

Yes, I Have Insurance But I Want To Pay Cash Instead

Molly Mulebriar vs Hospital Admissions Clerk

Texas Tech University Health Sciences Center To Pilot Project To Extend Trauma Care In Rural Areas

Texas Pilots EMS Telehealth Project to Extend Trauma Care

Direct Primary Care Access For $30 / Month

San Antonio, Austin or Houston – members can see a primary care physician 24/7 for a low monthly subscription rate of $30 at any one of 51 locations. Includes all lab work.

A Picture Worth A Thousand Words

Plan sponsors need someone sitting on their side of the table. Someone who knows all the secrets the health care industrial complex has kept hidden for years.

What Do PPO Discounts Really Mean?

We recently reviewed a proposal from BCBSTX on a large group wherein they guaranteed discounts of 79%! That’s very impressive!

Industry-First 3-Year Level Premium Health Plan

Vitori’s Vantage plan gives employers 36 months of Fixed Premiums for stable cash flow and predictable budgeting…………….

Legal ACA Strategies For Affordable Health Care

Eliminate:

Brand and Specialty Drugs

Organ Transplant Coverage

Deductibles

Co-pays

Co-insurance

AND…………

Sticker Shock At The Doctor’s Office — Why Do Hospitals Charge ‘Facility Fees?’

“Think of going to the grocery store to buy your milk and being charged a facility fee because you entered the store….When you can get access to this information in advance of care and upfront, you wouldn’t tolerate it. You’d go to a doctor’s practice that’s not going to charge you a facilities fee.” – Cynthia Fisher, Founder of Patient Rights Advocate

He Broke The Company Record By Selling 271 Policies In One Week

Taking a job as a door-to-door salesman for Combined Insurance the slick-talking salesman was a natural. He broke a company record by selling 271 policies in one week. Unfortunately, most of those were nullified when it was found he sold the bulk of them to patients at a nearby psychiatric hospital.

Deep State Administration Announces First Ten Drugs Selected For Price Negotiation

“Please tell me what is going on here… The release says these prices will go into effect in 2026.. We know when generic competition comes in, the prices drop massively. So what is happening?” – Chris Barakat on Linkedin

Employers Expect 7% Hike In Health Care Costs In 2024

Medical costs vs health insurance costs. Two different things. Legacy health plans believe they are one of the same. But they’re not. Want proof? A 900 life case has not had a rate increase in 15 years while improving benefits at the same time. Want more proof?

Walmart, CVS Want Patients To Skip Trips To The Doctor?

Drugstore disruptors? Walmart, CVS want patients to skip trips to the doctor

The big chains are angling for a larger slice of health care spending as new state laws allow pharmacists to treat minor ailments.

BCBSTX Machine Readable Files

QUESTION: How many consumers using other people’s money have either the time or the interest in looking up what things cost in healthcare? ANSWER: Zero. It doesn’t matter because their deductible, copays and coinsurance remain the same and that’s all they care about.

“The files may be large and download times may be significant. Internet speed, browser, and computer hardware may impact your download time/speed. Depending on your operating system, you may need to download a tool to open. There are various tools available on the internet; some are free and some are at cost.”

This Would Have Never Happened Under A Cash Pay Health Plan

She Paid Her Husband’s Hospital Bill. A Year After His Death They Wanted More

“The insurer had paid more than it owed, meaning the health system had to reimburse the insurer and charge the patient more.”

Life Insurance So Good They’ll Want You Dead

Ladder is life insurance you’ll love to get. Answer a few questions online and voilà! If you qualify, we’ll cover you with the click of a button. There are no hidden fees, and you can cancel or adjust your coverage anytime. Zero hassles, 100% love.

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.

Aldeen’s Sunday Morning Bathroom Read – Labor Day Edition

“The local not for profit facility has a choice to make: either accept the Charlie Brown lump of coal by way of hundreds of financial assistance applications and ongoing risk in perpetuity unless the member hits the lottery or marries an NBA player) OR enter into a direct contract with the plan at a very favorable rate.“

PBMs Adopt English Language Gymnastics

Documents and industry insiders suggest that PBMs’ pledges to pass the rebates (commissions) they get from drug makers back to their clients are a sleight of hand. In recent years, PBMs have changed what they call some of the money they take from pharma. Instead of rebates (commissions), these payments now go by such names as “administration fees,” “data fees” or “inflation protection.”

Non Profit Hospital System Demands 24% Price Hike

“Prisma Health is demanding a 24% price hike over 15 months that would increase health care costs by $63 million, with more than $46 million coming from the budgets of self-funded employers.” – UNITED HEALTHCARE

Plan Sponsor Agrees To Pay M.D. Anderson 85% of Billed Charges No Matter How Much It Is

This single case agreement stipulates the plan sponsor will pay 85% of billed charges, whatever it ends up to be, no matter how much it is. Based on past experience we expect paid amount will be in the neighborhood of 600-1,000% of Medicare rates or more.

Insurance Consultant In Hot Water

He Said, She Said

The Brownsville Independent School District’s insurance consultant finds himself in hot water during his presentation to the district’s insurance committee.

Help Wanted – Physician Position Open

Help Wanted. Family practice physician position offers complete independence, 8 hour work days with time off anytime needed. Daily patient load average of 8 patients per day.

Physician Contracts Are Changing

Alan Condon – Monday, August 21st, 2023

SOURCE: Physician contracts are changing (beckershospitalreview.com)

Shorter contracts, noncompete agreements and increased emphasis on value-based components are among the shifts occurring in physician contracts as hospitals and medical groups build recruitment pipelines and offer incentives to retain physicians.