October 2023 – Risk Managers

FairCo$t Health Plan

The FairCo$t Health Plan is an innovative plan design seamlessly integrated with a High-Performance Healthcare Solutions platform that provides best-in-class benefits at substantially lower costs while improving clinical and financial outcomes for health plans and their members.

Carrier Retains Right To Order Autopsy

A major carrier (one of the BUCAs) retains the right to order an autopsy but not in places where death is prohibited by law?

“The carrier shall have the right and opportunity to exam the person of the Participant for whom claim is made, when and so often as it may reasonably require during the pendency of a claim hereunder and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.”

Employee Benefit Meetings Are A Waste of Time

Smart Employees Are The Best Employees

We’ve been doing employee benefit meetings for a long time and conclude they are a waste of time and counter productive. Yet employers continue the practice. Why?

Why Insure Dental & Vision Benefits?

By James Farley

It always amazes me that benefit advisors will tell a plan sponsor that they should self insure their medical plan in order to save money and then turn around and sell that same plan an insured dental and/or vision plan.

GAG CLAUSE ATTESTATION REQUIREMENT DUE 12/31/2023

WHAT PLANS ARE REQUIRED TO COMPLY?

High Cost Claim Diversion Strategy Saves Plan Sponsors Big Bucks

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

“Exchange Dumping is a risk transfer mechanism whereby plan sponsors may induce high-risk plan participants to opt out of employer-sponsored coverage in favor of insurance available on the individual market. If properly designed, such an employer dumping strategy can promote the interests of both employers and employees by shifting health care expenses on to the public at large.” – Amy Monahan and Daniel Schwarcz, Associate Professors of Law at University of Minnesota Law School

County Adopts Cash Pay Rx Program With Outstanding Success

By Molly Mulebriar – Special To RiskManagers.us Blog

The Problem

A county’s self-funded health plan was bleeding. Prescription drugs were out of control, representing 50% of plan spend. County officials had to make a decision whether to continue their group plan or gift employees money to buy individual policies through an ICHRA.

Why A Patient Paid A $285 Copay For A $40 Drug

Americans pay more for prescription drugs than any country in the world, and the pharmaceutical industry earns billions in profits each year.

American Risk℠

Innovative Risk Transfer Strategies

“The Affordable Care Act (ACA) leaves self-insured employer plans virtually unregulated allowing employers a tremendous amount of freedom in designing the terms of their plans.”

Providers Cutting Ties With Medicare Advantage Plans

‘It’s a scam’: Why 2 practices no longer accept Medicare Advantage patients

How To Avoid High Cost Ambulance Services

When you wake up from being unconscious and they’re threatening you with an ambulance ride, run………………

Got a Bogus Medical Bill? Sue ‘em!

Small claims court flips the power balance in medical billing disputes. Pat Pawlowski shows us how it’s done.

Prescriptions Medications at Unbeatable Prices – Shop Smart, Save Big!

GHM Canada is a game-changer for American self-funded companies, providing them with a cost-effective solution to manage their prescription medication expenses.

Who’s Driving the Craze for Ozempic, Other Weight Loss Drugs

Extensive media coverage and high obesity rates are fueling interest in prescription weight loss drugs, writes deputy head of industry intelligence Nicki Zink.

What Do PPO Physicians & BUCA Brokers Have In Common?

The BUCAs have it both ways. They control product services and market distribution.

Wanna A Peek At A Blue Cross Hospital Contract?

The Power Of An Annuity…………………

As a kid were you ever told NO! you couldn’t have something? That’s when you wanted it even more and would do anything to get it. We were told some years ago by a Blue Cross official “Bill, you will never get a copy of one of our hospital contracts, so stop asking!”

Hope For Fat Kids As Young As 6 Years Old

SOURCE: The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants

The already booming market for weight loss treatments like Ozempic might get even bigger as drug companies seek to make them available for children. The CDC estimates that ~20% of kids 6+ in the US have obesity, and manufacturers are working to make their weight loss drugs available for that age group.

Chocolate Factory Appointment

“Honey, I have an appointment at the Chocolate factory this afternoon. I may be late for dinner so you might want to bring some take out home for dinner” says Christina to her husband.

How To Make Health Care Free

Watch Here: How to Make Healthcare Free for Your Employees | LinkedIn

Is free employee #healthcare really possible in a market where costs are expected to increase to the highest they’ve been in a decade? We think so!

Middlemen Pocket 70% of Medicare Spending On Widely Used Generic Drugs, Study Finds

Victor Lustig Would Be Proud

This article hints of the money flow distribution through third party intermediaries. Prescription drug commissions (rebates) average 30-40% of total plan Rx spend inclusive of generic and brand name drugs. This article outlines a breakdown of who gets paid what through generic drugs: 40% to the PBM, 17% to retail pharmacies, 12% to wholesalers, leaving 30% for the pharmaceutical manufacturers.

How To Impress Your Girlfriend

Aldeen’s Sunday Morning Bathroom Read

By Doug Aldeen

Bottom of first inning:

Citizens and Plan Sponsors of the State of Wisconsin Antitrust Case (1): vs. Aspirus Health (Regional Monopoly) (0)

PBM Is Transparently Honest

I was introduced to yet another PBM this week – Benecard. A fellow consultant highly recommended I check them out. So I went to their website.

Plan Sponsor Screws Plan Members

By Bill Rusteberg

I just ran the numbers on a 2,500 life school district and you may be surprised by the results.

Don’t Ever Pay A Hospital Bill Without……

By Bill Hennessey, M.D. – Chief Innovation & Billing Integrity Officer

Hospital MUST Provide Itemized Bills Before Payment or Collections
and This Should Be a Law in All 50 States…………

Gary F. Slavearbejderen Has An Epiphany

Gary F. Slavearbejderen, a group health insurance broker, works hard for his money and takes a lot of abuse from unhappy claimants at the same time. He has to keep up with ongoing federal regulations continuously advising his clients about new developments in a fast moving industry. Gary earns a hard $350,000 a year.

Next Insurance

NEXT is an admitted carrier NEXT Insurance: Small Business Insurance Quotes offering small business insurance to over 1,300 professions. Start selling with us as soon as today.

Brownsville ISD Changes Logo

The Brownsville Independent School District, the largest employer south of San Antonio, will be changing logos on their self-funded health plan effective January 1, 2024.

Pharmaceutical Sales Reps Penned Up

SOURCE: Inversionism

This is Dr. Jeffrey Caren’s 1200+ pen collection that he amassed over 6 years of pharmaceutical reps coming to his office to try and get him to prescribe their drugs.

Killeen ISD To Save $10,000,000 By Joining Government Health Plan

At their September 2023 board meeting TRS ActiveCare officials approved transitional rates for the Killeen Independent School District (KISD). KISD is joining the TRS ActiveCare program effective January 1, 2024.

New Medical Dictionary Released

Employer Lawsuits Heat Up Against Health Plan Administrators

Employers are obligated to make sure “that there are no hidden fees and expenses and limitations” on audit rights in the contracts they enter into with service providers.

An Offer You Can’t Refuse

A Texas school district is out to bid for a new health insurance consultant. The usual suspects will apply and the outcome is predictable. A brand name, national brokerage/consultancy will win the account and life will go on with little changed.

MDsave

All-Inclusive Healthcare Pricing

Take the guesswork out of your healthcare spend. Get access to a network of local providers offering procedures with upfront prices and exclusive savings. No middlemen. No surprise bills.

How Much Do You Charge?

By Bill Rusteberg

Invariably we are asked at our first meeting “How much do you charge?” Here’s how we answer:

Lawsuit Exposes How Health Insurance Brokers Can Earn Enormous Commissions

By Bill Rusteberg

“You Don’t Want Me To Know Your Business Because It Won’t Be Good For You!”

“When Will The Reaper Come For Employer Health and Welfare Plan Sponsors?”

General Electric will pay $61M in ‘largest ever’ 401(k) mismanagement suit

ARTICLE REFERRED BY NEIL QUINN with note: “When will the Reaper come for employer health and welfare plan sponsors?”

Healthcare Retailers In The News

Healthcare retailers in the news: Best Buy Health, Walgreens, Dollar General

Dave Pearson | October 10, 2023 | Health Exec | Business Intelligence

The past several days have seen a series of noteworthy healthcare developments involving brick-and-mortar consumer stores. Here are three (plus one).

Everyone Is Paying For Mary’s Deductible Because Mary Isn’t

Lucky Mary. She has a $1,500 deductible through her employer’s health plan but everyone else is paying for it because she’s not.

The Service Contract Act

Federal Workplace Posters | How to Start an LLC

The 2023 Service Contract Act fringe rate was announced in July 2023 at $4.98 or $4.57 per hour. Employers can offer employees fringe benefits in lieu of a cash payment.

Fair Market Payment(TM): Big Savings, Less Friction than BUCA or RBP Plans

Hospital Administrator Reacts To RBP Payment

By Joe Candio

We help employee benefits brokers and consultants achieve better outcomes, save 25-35%, and provide an overall better member experience for their clients and prospects

OneTest™ for Cancer

Transform your practice with OneTest™ for Cancer. The affordable multiple cancer screening test that makes early detection accessible to your patients. Offer this cutting-edge technology and attract more patients, enhance their experience and boost revenue

Another Great Butler Analogy

Josh Butler – President, Butler Benefits

What if your employer were responsible for withholding money from your paycheck every pay period and tasked with buying your groceries each week?

Mary Lou Retton In ICU – Has No Health Insurance

Mary Lou Retton ‘fighting for her life’ with rare form of pneumonia, daughter says

By Jack Baer Tue, Oct 10, 2023

Gymnastics: 1984 Summer Olympics: USA Mary Lou Retton victorious with medal after Women's Individual All-Around competition at Pauley Pavilion.
Los Angeles, CA 8/3/1984
CREDIT: Jerry Cooke (Photo by Jerry Cooke /Sports Illustrated via Getty Images)
(Set Number: X30344 ) — Mary Lou Retton started something in American gymnastics that is still going. (Photo by Jerry Cooke /Sports Illustrated via Getty Images) (Jerry Cooke via Getty Images)

Mary Lou Retton, the first American woman to win all-around gymnastics gold at the Olympics, is “fighting for her life” with a serious illness, according to a fundraiser posted by her daughter.

Insurance Business For Sale For A Piddling $10,000,000,000

Truist in talks to Sell Insurance Business for $10 Billion………….

Pickle Ball To Cost Millions In Healthcare?

Pickleball-related injuries will cost Americans $377 million in health care this year, making up 5% to 10% of total unexpected medical costs in the country.

Learn How To Make Healthcare Free For Your Employees

Vitori Health Announces Acquisition of Flume Health’s TPA Operations

Tue, October 10, 2023

Kansas City, Mo., Oct. 10, 2023 (GLOBE NEWSWIRE) — Vitori Health, a national precision-built health plan solution that provides a high-performing alternative for mid-market employers and their employees, announced today its acquisition of Flume Health’s third-party administrator (TPA) operations.

Lower Rio Grande Hospital Pricing Study Shows Plan Sponsors Getting Screwed

Recently we ran 100% of 12 months of paid hospital claims through several payer systems, both inpatient and outpatient, on a group of 225 employee lives in the Lower Rio Grande Valley, Texas. We used a firm that reprices claims for a number of PPO networks as well as out-of-network claims using Medicare and Medicaid benchmarks.

Third Party Intermediaries Make Up 45% Of Healthcare Spend

Direct Primary Care coupled with Cash Pay Centric Health Plans eliminates costly middlemen, providing better, more efficient health care at half the cost of traditional managed care plans.

BISD Board Member Censured For Calling Insurance Consultant A Liar

To be branded a liar publicly for all to see affects an independent consultant’s ability to attract and retain clients now and in the future. The damage is irreversible, Feathers In the Wind.”

Bob Reim Insurance Newsletter

Prior to 2020 the United States averaged 7.9 billion-dollar-damage weather disasters each year. The average for the last three years has been 20 billion-dollar-plus, and as of September 2023, the United States has already set an unfortunate record of 23 billion-dollar-plus, with over a quarter of the year still to come.

How UnitedHealth became Goliath, Medusa and mythical sirens all wrapped into one

By WENDELL POTTER – OCT 5, 2023

America’s biggest health insurer and I have something in common. Next year, we’ll both be celebrating 40 years in health care. One of us is worth a lot more money.

Excess Re

Excess Reinsurance Achieves Performance Assessment Rating of PA-2 (Excellent) by AM Best

MyHealthGuide Source: Excess Reinsurance 10/7/2023

Woodbury, NJ — Excess Reinsurance, a leading player in the stop loss insurance industry, proudly announces that it has been awarded a Performance Assessment Rating of PA-2 (Excellent) by AM Best, a globally recognized credit rating agency specializing in the insurance industry.

The American Health Care Crisis – Is It Time For Civil Disobedience?

By Bill Rusteberg

The American health care delivery system has reached a boiling point. The average working American can no longer afford health insurance and those who can often find they can’t afford to use it.

How to Prepare For Possible Health Plan Litigation

SOURCE: How to Prepare For Possible Health Plan Litigation | PLANSPONSOR

Fiduciaries and service providers should act now to mitigate the legal risks associated with lawsuits alleging health plans paid unreasonable and imprudent fees and expenses.

The C-Suite Solution

Jeff Evans, CRM, ACSF Passionate Risk/Insurance Educator-Coach-Author

Please don’t miss your chance to get your FREE copy of Healthcare’s C-Suite Solution.\

Capital Rx Employee Shitcanned

Brianna Pinnix, a 30-year-old talent acquisition specialist at Capital Rx lost her job this week.

Texas School District Seeks Insurance Consultant

The Mission Independent School District is seeking an insurance consultant.

Risk Tolerance – The Fundamental Basis of Goal Setting

The problem I see with most health insurance consultants is almost all pre-determine a client’s tolerance for risk before determining where the risk tolerance actually lies.

Hospitals and Their BUCA Moat Must Go Bye Bye

By Bill Hennessey, M.D.• Chief Innovation & Billing Integrity Officer

Non-profit hospitals have been known to send hate mail to employer groups using reference-based pricing (RBP), meaning a health plan that is not Blue Shield, United, Cigna or Aetna (BUCA). This illegally denies access to care the very working poor entitled to free care under the ACA IRS 501r, dating back to March of 2010.

Selling A Health Plan Without A Logo Is Hard

I can sell a health plan that guarantees double digit rate increases year after year along with increasing deductibles and out-of-pocket costs ultimately resulting in functionally uninsured plan members whose employer “cares about them.”

Aldeen’s Sunday Morning Bathroom Read – “NOPE”/RBR Plan Renewal Edition

By Doug Aldeen ERISA Healthcare Attorney and General Counsel

Sunday Morning Bathroom Read “Nope”/ RBR Plan Renewal Edition (second in an ongoing series):

Is a not for profit facility able to request charges upfront from a patient ( who has less than adequate insurance read: RBR) without first determining eligibility under their financial assistance policy prior to treating for medically necessary elective services?