November 2023 – Risk Managers

Education Insurance & Risk Management Program

It’s hard to keep secrets in the insurance industry but in this instance the TEE Mystery Insurance Program wins the 2023 Best Kept Secret Award. As a GCISD board member recently stated during a TEE presentation, “If you are scared to answer my questions then that right there is a big red flag.”

12 Year Old Company Now Employs 10% of All American Physicians

Founded only 12 years ago, Optum now employs 10% of all American physicians. Optum is a United HealthCare company. Imagine, 90,000 doctors working for an insurance company! Who’d ever thought!

The Year 1907

In 1907 the average life expectancy in the U.S. was 47 years old. Five leading causes of death in the U.S. were:

David Beckham’s Leg & Face Insurance

By Paul MillerPaul Miller

When he left Manchester United to join Real Madrid in 2006, Ferdinand’s United and England teammate David Beckham covered himself at Lloyd’s with a £100 million policy.

Rebellion Brews Among Texas School Districts

By John Petree – Nov 27, 2023

SOURCE: Opinion: TEE Is a True Disruptor and Here To Stay

Within the last few weeks, something big has happened: two public independent school districts in Texas have begun the journey to separate from the Texas Association of School Boards (TASB) and become official partners with the state’s first true alternative service provider, Texans for Excellence in Education (TEE).

The Economic Impact Of A Line On A Map

South of the line (USA) prescription drugs are more expensive than those purchased north of the line (CANADA).

50 Million People Can’t Afford Group Health Insurance

Why Having a Group Health Coverage Better ? – Independent Health Agents

More Americans are turning to individual health insurance policies because for many of them the government is paying for most of it.

“For many of the almost 50 million people working for the 3.2 million smaller companies in America, family coverage is no longer affordable.

State Health Plan Blames Weight Loss Medication On Budget Deficit

“I can eat all I want because my employer covers Ozympic and Wygovy!”

“At their November meeting, the SEBC noted weight loss medication coverage as a large contributing factor to the deficit.”

The Blues Open Medical Clinics Across The Fruited Plains

Double network revenue turbocharges profits for the non-profits?

“In recent years, BCBS plans opened medical clinics that exclusively serve their members. Premera Blue Cross partnered with Seattle-based Kinwell Medical Group in 2022 to open primary care clinics for its members in Washington state.”

Public Service Announcement For Texas Educators – How To Instill Discipline In The Classroom

Clinic Manager Advises Patients When Cash Price Is Cheaper Than Insurance Prices

By Marshall Allen

I recently got an interesting email from the clinic manager at a private psychiatry office. She has been reading Never Pay the First Bill and wanted to allow her insured patients to pay cash when the cash price was lower than their insurance company discounts. But she worried her insurance company contracts prevented it.

Edinburg ISD Canadian Rx Cost Analysis Illustrates Enormous Savings To Be Gained

The Edinburg Independent School District’s self-funded health plan is hemorrhaging. Plan costs have increased 100% over the past five years driven to a large extent by specialty drugs.

Affordable Care Act 2010-2023

The growing role of government in health care finance since 2010

By Tom Daly

Since its enactment in 2010, the Affordable Care Act (ACA) has undergone several significant changes. These alterations reflect efforts to adjust, improve, or challenge various aspects of the law.

The US Doesn’t Have Universal Health Care— But These States (almost) Do

Ten states have uninsured rates below 5 percent. What are they doing right?

By Dylan Scott @dylanlscott Nov 26, 2023

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Universal health care remains an unrealized dream for the United States. But in some parts of the country, the dream has drawn closer to a reality in the 13 years since the Affordable Care Act passed.

Why Does Your Self-Insured Health Plan Need A Network?

By Dutch Rojas

In a bold move shaking up the corporate healthcare scene, many, that’s a lot, large companies are discarding traditional health insurance networks.

National TPA’s Niche 20-500 Lives

Texas Senate Bill 2476 – Ground Ambulance Balance Billing

Expands current balance billing prohibitions to include ground ambulance services. Rather than applying the independent dispute resolution process, SB 2476 directs TDI to create an emergency service provider balance billing rate database. Health plans must reimburse ground ambulance services at:

Too Embarrassed To Ask?: What Is Moral Hazard?

Moral hazard in health care is common. Here’s two examples:

How Liberty HealthShare Left Thousands With Debt as It Built a Family Empire

A Christian Health Nonprofit Saddled Thousands With Debt as It Built a Family Empire Including a Pot Farm, a Bank and an Airline

by Ryan Gabrielson and J. David McSwane

Despite a history of fraud, one family has thrived in the regulatory no man’s land of health care sharing ministries, where insurance commissioners can’t investigate, federal agencies turn a blind eye and prosecutors reach paltry settlements.

Aldeen’s Sunday Morning Bathroom Read

“Think about it: It is just like H&R Block “maximizing your tax refund”… except you and your family are headed to Disney courtesy of the local not for profit facility” – Doug Aldeen

No One’s Promising You Can Keep Your Doctor Anymore

“It’s no longer viable to go it alone and administrative requirements from insurance companies are time-consuming and burdensome. That’s killing things. It’s just so incredibly complex” – Allen Ditto, M.D.

ICHRAs VS “One Size Fits All” GROUP HEALTH INSURANCE

Are Non-Profit Health Insurance Companies The Future Of American Healthcare?

The American health care system is financed through for-profit insurers while a Bismarck health care system is not. American health care is racing towards a major upheaval and the BUCAs know it.

HealthSherpa Enrolls 2,430,000 Americans On FREE, or Almost Free Individual Health Insurance

Where else can you get free or almost free health insurance these days? Third party intermediaries like HealthSherpa, Milliman, Nexben, Take Command Health and many others provide enrollment assistance to help make that happen……………

Get Ready! Plan Members Will Be Receiving Emails Like This!

Plan Sponsor Reacts To Lawsuit Brought By Employee Johnny Sixpak

“If you currently participate in [company name]’s Healthcare Plan, you may have a legal claim. Are you a current [company name] employee who has participated in the company’s healthcare plan? You may have a legal claim — and we’d like to speak with you. Contact our office today for a no-obligation, confidential consultation. At Schlichter Bogard, we protect whistleblowers.

Destroying Relationships For A Living

Selling health insurance is a tough business. It’s not a created sale, it’s a replacement sale which means relationships must be destroyed before any chance of a sale is possible. Destroying relationships takes time, effort and money.

Lloyds of London Revisited

This reproduction of Lloyd’s Coffee House was put on display in the ’28 Building for the 1951 Festival of Britain.

Lloyds of London: Hollywood Insurance

An injury almost ended Nicole Kidman’s career because insurance became too expensive for her production company to cover.

Dentists Rejoice: Government Eyes Unlimited Dental Coverage For All

A typical dental plan today is usually limited to $1,000 to $1,500 annual maximum. The government wants to treat dental care as an Essential Health Benefit with unlimited coverage.

Transplant Record Holder

Great Salesman Don’t Need A Stinking MBA

Sales is a profession like no other. Unlike most other professions, salesmen are paid exactly what their worth, nothing more and nothing less. Most are graduates of the School of Hard Knocks.

Foot Locker, Teamsters Show Their Drug-Benefit Managers the Door

Employers and unions are getting fed up with the firms they have used for years to help control their spending on prescription drugs—because their costs keep soaring.

Employers Have Up To 86 Reasons To Rejoice!

The Baskins-Robins “Pick Your Favorite Flavor” Approach To Health Care

By Ich Ra

Why not give your employees a choice of up to 86 different ACA approved plans through four (or more) different brand name insurance companies (instead of just one as you have now) while limiting your contributions to whatever your budget allows on a per employee per month basis?

BUCA Provider Network Lookup

Below are the provider lookup links for each of the BUCAs:

Mark Cuban Is Taking On Big Pharma

Mark Cuban is taking on Big Pharma, in a quest to help employers lower drug costs

School District Considers International Rx Sourcing & Independent Claim Audits

Watch the Ednburg Independent Insurance Committee learn (1) Their Rx spend is up 26.3% over last year, from $162.79 to $203.21 pepm, (2) International Rx sourcing could save over $600,000 on just one drug alone (Ozempic) and (3) Why Independent claim audits aren’t necessary because “Blue Cross audits every single claim.…..you’re only paying 29.6% of allowed charges.” NOTE: “Allowed Charges” are not billed charges.

Juan Demonstrates How To Nail An Appointment In Under 45 Seconds

The Ben Feldman Cold Call Approach

Juan makes cold calling look easy. Here he demonstrates his unique cold calling approach to setting an appointment with a perfect stranger in less than 45 seconds.

Yuzu Health

Powered by $5M investment, startup Yuzu Health takes on insurers’ ‘brittle’ technology

By Noah Tong Nov 1, 2023

Entrepreneur Max Kauderer thinks the company he has co-founded, a third-party administrator called Yuzu Health, can disrupt major insurance companies by helping offer small businesses more affordable health plans for its employees.

Most Texas School Districts Don’t Know This

Sec. 1501.009 of the TEXAS INSURANCE CODE stipulates an independent school district may elect to participate as a small employer without regard to the number of employees in the district.

Warren Touts Lower Cost Workers Compensation Insurance

Warren says companies will save up to 20% on their Workers Compensation insurance by dealing direct with his insurance company. He says you can get a quote and get covered online in minutes.

The Power of Small In American Health Care Finance

By Bill Rusteberg

Want to escape punishing government oversight of your employee health plan? Want to reduce or eliminate your second largest company expense? Become a small employer and be happy.

Cross-Plan Offsetting: Robbing Peter To Pay Paul

Department of Labor Settles Cross-Plan Offsetting Case

Cross-plan offsetting refers to the practice by which a health plan insurer or TPA recoups alleged overpayments to a healthcare provider under one plan by reducing subsequent payments owed to the same provider or plan participants under a different plan.

Marpai Appoints Lamendola CEO, Dendy Joins Board

Marpai Names Damien Lamendola as Chief Executive Officer to Drive the Next Phase of its Growth; Names Mike Dendy to Board

Texas & Tennessee Pass Legislation Turbocharging Cash Pay Claim Strategies

Article Referred by Mike Dendy

Many Americans are often overpaying for services when they use their insurance…….Why pay $2,400 when you can pay $541? More plan sponsors are adopting cash pay claim strategies……………

New York State Requires Cancer Insurance For Vol. Firefighters

The New York State Volunteer Firefighter Enhanced Cancer Disability Benefits Act requires every fire department and company in the state of NY with eligible members must show proof of coverage.

ICHRA Administrator Releases 3rd Annual Report

SOURCE: New Report From PeopleKeep Highlights Employers’ Robust Use of ICHRAs to Cover Higher-Tier Health Insurance Plans (benefitslink.com)

SALT LAKE CITY — PeopleKeep, the leader in personalized benefits for small and midsize organizations, released its third annual report on the individual coverage health reimbursement arrangement (ICHRA).

Lower Your Medical Bills With Resolve

Resolve reviews and reduces medical bills on your behalf. We’ll lower your bills or our service is free. Guaranteed. – Start Lowering Your Bills

Death Receptor’s Kill Switch Turns Cancer Cells Room Temperature

In potential cancer breakthrough, newly found ‘kill switch’ triggers death of cancer cells: ‘One-two punch…………………..

The Machine Will See You Now….

Self-serve CarePods use artificial intelligence to screen and diagnose health conditions

Replacing doctors with machines. Next thing you know they’ll be installing self-serve checkout kiosks at the grocery store and self-driving cars to get you there!

Revolt Healthcare

Fixed Benefit & Income Protection In Action: Doctors Visit – $120 Benefit, Chiropractic Visit – $120 Benefit, Specialist Visit – $150 Benefit

I Told You So…………

By Mary Talley Bowden MD

Two years ago today, I received a text message from the Houston Chronicle letting me know Houston Methodist suspended my privileges for speaking out against mandates.

First Primary Care Develops DPC Integrated Health Plans

By Chris Barakat

We at First Primary Care have been doing some never seen before things to help our broker/advisor partners achieve their mission to help deliver health benefits to their clients.

Aldeen’s Sunday Morning Bathroom Read – Caesar Crossing The Rubicon Edition

Minnesota, by simply removing the burden from the patient to the facility to establish eligibility under its financial assistance policy, is the market equivalent of Julius Caesar crossing the Rubicon.

Mission ISD Selects Insurance Consultant

Two Vendors Leave Board Meeting Singing…………..

Here’s more proof most decisions are made before board meetings begin. Vendor presentations are entertaining but seldom make a difference………….

Veterans Day 2023

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart.

I knew little of my father’s participation in WW2 until after he died. Unlike veterans of today his generation didn’t talk much about it. Their quiet pride was enough, understood by all. The following recounts the Battle of Hatten in which my father was a participant. – Bill Rusteberg

Special Legislation Brings New Health Plan Option For Texans

Article Referred By Doug Aldeen

We’ll cut right to it:

We created a new healthcare company specifically for small businesses in Texas. We built it because small business owners want to provide health coverage so they can do right by their employees. And employees want to protect their families.

Why Diet or Exercise When All You Have To Do Is Swallow A Pill?

Weight Loss Drugs Add $300 to Each Employee’s Health Costs Even If You’re Not on One

“Weight loss prescriptions Wegovy, Rybelsus and Saxenda — along with Ozempic — are driving health costs for employers up by more than $300 per insured worker this year .

Frontier DPC Blitzkreig In Deep South Texas Liberates 10,000 Fee-For-Service Consumers From Managed Care Hell

“We now have 7 clinics in the RGV; 8 by the end of 2023; Weslaco, Pharr, McAllen (2), Harlingen, Brownsville, Raymondville and Edinburg by year-end. We employ 34 medical professionals with a plan to hire an additional 20+ by year-end. 18 months ago we had 1,500 members and today we have nearly 10,000 under contract.”

Thinking About Leaving TRS ActiveCare?

Is The Grass Greener On The Other Side?

Most districts exiting the government health plan have failed while others have achieved unusual success. What makes the difference?

By Bill Rusteberg

It’s that time of year again when districts across the state are considering their health insurance options. Do they continue with TRS ActiveCare (TRSAC) or seek coverage on the commercial market? They have until December 31 to make their decision.

Fascinating Interview of A Former Texas Drug Pusher

Starting as a 21 year old pharmaceutical sales rep. in Waco, Texas on a $17,000 a month “use it or lose it” expense account, this former drug pusher talks about his experience in the pharmaceutical industry, insurance companies and it’s effects on primary care physicians.

“Keep Raising Your Prices!”

By Ryan Miller (Visit my website)

People pay for the outcome you produce for them, not the product or service you sell.

TRS ActiveCare’s New Rx Program Under Fire

“Prescription Drugs Are Too Damn High!

Change in prescription drug coverage leaves employees without medicine

Want Out Of TRS ActiveCare?

TRS ActiveCare member districts wanting out of the government program can simply stop paying premiums at any time. However, the TRS ActiveCare Paper Tiger reserves unspecified “remedies” to punish wayward districts.

Help Wanted: Assist Hospitals In Their Charitable Mission

‘Attention Employers, Give Me Your Poor, Your Tired, Your Huddled Employee Masses………….” – The Great Aldeeni (Pictured above during his college years)

This Blog Entry Dedicated to Doug Aldeen, The Godfather of 501r

“Nonprofit hospitals are going to need help changing their behavior.”