December 2024 – Risk Managers

Risk Management Strategy For Type 2 Diabetes

“We will cover GLP-1 for type 2 diabetes as long as you participate in the therapeutic journey to help you achieve remission and be healthy.” – Quote Stolen From Jeff B.

The New Retirement: Baby Boomers Who Are Not Slowing Down

SOURCE: Dallas Expresss

In a shift from traditional retirement, a growing number of baby boomers are choosing to work well into their sixties and seventies.

How Much Would The Texas State Employee Health Plan Save At 200% of Medicare?

Visualizing the Impact of the Hospital Payment Caps

The Hospital Payment Cap Simulator provides anyone from policymakers to researchers with insights into how much state employee plans across the US could save from hospital payment caps and the impact on commercial hospital operating margins. Read the instructions below to learn how to use the tool.

What Is Elon Up To Towards Solving Health Care For His Starbase Employees?

By Bill Rusteberg

Elon Musk has transformed Boca Chich beach into a mega space exploration center by investing over $3 billion mere yards from the Gulf of Mexico. Last we heard there are more than 3,000 employees working there.

They Were Entitled to Free Care – Hospitals Hounded Them to Pay

More than half the nation’s roughly 5,000 hospitals are nonprofits like Providence. They enjoy lucrative tax exemptions; Providence avoids more than $1 billion a year in taxes. In exchange, the Internal Revenue Service requires them to provide services, such as free care for the poor, that benefit the communities in which they operate.

Another South Texas School District Robs Employees of Better Benefits

Another Lower Rio Grande Valley school district gifts employees $4.8 million Christmas Bonus robbing plan members of better health insurance. The McAllen Independent School District gifted millions too as a “retention” bonus.

Type 2 Diabetes Remission Program For The Lower Rio Grande Valley

“The Rio Grande Valley has one of the highest rates of diabetes in the entire country. The rate is 18% above the national average, according to recent data from the University of Texas Health School of Public Health in Brownsville. Oftentimes, a lot of people don’t even know they have diabetes.”

Health Insurance Commissions vs RiskManagers.us Fees

Since transitioning from commissions to fee based consulting in 1997 I’ve often found plan sponsors reluctant to accept our fee schedule. “That’s too much! We don’t pay our broker anything, the carrier pays his fee!”

What Is An Actuary?

“An actuary is a person who passes as an expert on the basis of a prolific ability to produce an infinite variety of incomprehensible figures calculated with micro-metric precision from the vaguest of assumptions based on debatable evidence drawn from inconclusive data derived by persons of questionable reliability for the sole purpose of confusing an already hopelessly befuddled group of persons who never read the statistics anyway.” – Daren Daley, Perr & Knight

80% Want Higher Health Insurance Rates

“Among U.S. adults, 80% say insurers should cover weight loss drugs for adults diagnosed as overweight or obese.”

Elon Musk’s ‘Ozempic Santa’ Post Turns Heads

Alyssa Goldberg – USA TODAY

On Christmas Day, Elon Musk turned heads with a decadent photo by his tree. Dressed head-to-toe in a Santa costume, he captioned his photo “Ozempic Santa,” flaunting a slimmer figure.

QUOTE OF THE DAY

“If your broker had you auto renew with either BCBS or UHC, you paid them $20-$50 a month per employee to buy what you need zero advice for. You don’t need to pay someone to buy McNuggets.” – BJ Spyksma, CEO Apios

Are School District Cafeteria Plans Accepting Illegal Inducements?

Texas public school districts routinely employ third party administrators at no charge to act as a single source premium remitter with convenient online enrollment capabilities in return for the privilege of selling commission generating insurance products.

This Independent Assessment Can Save Employers Billions On Healthcare

“81% of employers unknowingly expect a fox to guard their hen house, and this is why some leading ERISA attorneys consider the use of brokers for consulting and procurement illegal.”

Fixed Indemnity Insurance Consumer Notice Abolished By Federal Court

Federal court rules consumers are not so dumb they don’t understand what they are buying.

Bay Bridge Administrators

Bay Bridge Administrators is a full-service, nationally recognized, third party administrator of fully-insured employee benefit plans. We are licensed and bonded and we represent only top-rated insurance companies.

UnitedHealthcare & The ObamaCareCon

By Allysia Finely

“We’ve gotten to a point where healthcare is so inaccessible and unaffordable, people are justified in their frustrations,” CBS News medical contributor Céline Gounder said during a Friday segment on the roasting of health insurers…

The Story of ‘Santa’s Last Journey’

Article Referred By Jody Bright

“Rumors are flying around Washington to the effect that this may be Santa Claus’ last year of operation. Sources within the Federal bureaucracy are privately indicating that the jolly old man is in big, big trouble!”

RiskManagers.us 2025 Fee Schedule

“RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.“

The following is the RiskManagers.us 2025 Standard Fee Schedule and Consulting Agreement for new business:

ICHRA Administrator Raises $100,000,000

“ICHRA provides Remodel’s customers with predictable annual benefits costs, driving stability and an average of 30% savings….”

Don’t Cancel Your Life Insurance, Sell It

COVID Crusader Calls On Paxton To Investigate The Texas Medical Board

SOURCE: Dallas Express

Houston ENT Dr. Mary Talley Bowden has called on Texas Attorney General Ken Paxton to launch multiple investigations into the conduct of the Texas Medical Board.

RiskManagers.us Offers Post Graduate Course For Plan Sponsors

If you wish to continue operating your self-funded plan the old fashion way this advanced course will not be of interest to you – Homer G. Farnsworth, PHD

Half of Nueces County Residents Don’t Need Health Insurance

Attention Employers, Give Me Your Poor, Your Tired, Your Huddled Employee Masses………….

Attention Nueces County residents! You may qualify for free or near free hospital care courtesy of your local, non-tax paying, not-for-profit hospital system.

School District Xmas Bonus Robs Plan Members of Better Benefits

At a December school board meeting a one-time taxable gift of $600 was approved for all 3,254 full-time employees to “build morale.” Could there have been a better way to invest $1.9 million for a greater return on investment for the benefit of valued employees?

Texas School Districts Asked To Return Millions In Medicaid Funds

The Texas Health and Human Services Commission sent an email this month to 552 school districts statewide informing officials they would need to pay anywhere from $100 to $800,000 back to the department for services billed in 2011. The charges stem from a 2017 federal health agency audit that found Texas had improperly billed the agency 238 times for services under the School Health and Related Services program

FDA Ruling Bars Cheaper Copies of Weight Loss Drugs

US FDA says Lilly’s weight-loss drug shortage is resolved

The U.S. Food and Drug Administration said on Thursday there was no longer a shortage of Eli Lilly’s (LLY.N) blockbuster weight loss and diabetes drugs following a re-evaluation of their supply by the agency.

The finding effectively bars widespread sales of cheaper copies of the drugs that many patients use, but the FDA said it would not take any action against the compounding pharmacies that make them within 60 to 90 days of the decision.

Motorist Gifts Free Christmas Tree – Insurance Pays Damages

Mr. Fairclough was driving home from Christmas shopping, when he saw a car coming the other way with a Christmas tree badly tied to its roof.

Coco Puffs & Cigarettes

“I’m curious though – why is it that we wouldn’t give our kids a cigarette for breakfast, but we would give them an ultra-processed food with added sugars and refined grains?”

This Is What Happens When HR Takes Over Corporate Health Care

This is a true story.

The graph above shows how a plan can lower their cost and increase benefits at the same time by following common sense risk management strategies. This case did just that for three years in a row.

Then something happened.

Mike “The Headless Chicken” Introduces House Bill 541

Texas HB 541 Screws With Direct Primary Care – If it’s not broken fix it until it is.

“Billing insurer or health maintenance organization prohibited.”

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.

Texas HB 1612

Readers Digest Condensed Version: If you don’t have health insurance and accrue hospital bills you cannot be billed more than 25% more than what the hospital accepts from it’s lowest BUCA reimbursement rate

Professional Liability (E&O) Insurance

Consultants save up to 20% on your business insurance. Get a quote and get covered online in minutes.

Democrats Rave About Viagra Alternative

Big news out of Washington – Democrats fixated on Donald J. Trump’s Erection, conduct public hearings.

Top Cardiologist: 100 Million Vaxxed Americans Now Have Irreversible Heart Damage

Article Referred By Jody Bright

A leading cardiologist has warned that over 100 million Americans may now have irreversible heart damage after receiving Covid mRNA “vaccines.”

Trump To PBM’s: YOUR FIRED!

“The horrible middleman that makes more money, frankly, than the drug companies, and they don’t do anything except they’re a middleman. We’re going to knock out the middleman,” – Donald J. Trump

Hospital Price Transparency Files Reveal The Stakes In The Fight Between Two Healthcare Giants

“As calls to improve upon the foundation of hospital price transparency appear to be ignored and as price disclosure appears to be eroding, we believe that even the limited insights that these files present are a good indication that broader and more comprehensive price disclosure across the healthcare and insurance delivery systems are a good thing for purchasers.”

Short Term Medical Insurance

Check out rates for short term medical insurance HERE

Novo To Buy Catalent

Regulatory conditions on Novo Holdings’ $16.5 billion Catalent deal fulfilled, companies say

By Reuters

Dec 14 (Reuters) – All regulatory closing conditions related to Novo Holdings’ $16.5 billion acquisition of U.S. contract drug maker Catalent (CTLT.N), opens new tab had been fulfilled, the companies said on Saturday, adding that the transaction is expected to be completed in the coming days.

Growing Government Focus On Level Funded Plans

“As one who believes ERISA self-funded plans are the optimal tool for employers to economically customize health benefits for employees and dependents, I am concerned with the growing effort to weaken ERISA. Below are briefs from recent articles and initiatives that supporters of self-funding should be aware. The focus is largely the result of the growth in level-funded health plans” – Ernie Clevenger

30% Savings With Premise Health

When people are healthier, their organizations can thrive. In a claims-based analysis of 207,000 eligible lives from across 26 organizations, the results were clear: advanced primary care leads to better health and lower healthcare costs. The study methodology was validated by Milliman, an independently recognized actuary. Read success story

Optimyl Benefits

Optimyl Benefits is an emerging leader in the group health space, delivering a turnkey level-funded program to small employers that is setting new standards for flexibility and transparency.

PerfectQuote

PerfectQuote is an Austin, Texas company founded in 2017 by brokers for brokers, focusing on delivering operational excellence and client satisfaction through technology in the commercial group health insurance industry.

Medical Insurance Captive Lowers Expense Load 25% for 2025 Treaty Year

“We are simply more efficient than other methods of purchasing a medical stop loss policy. This efficiency allows us to price our premiums at or below market rates AND give back ~ 27% of the member’s paid premium.”

Attn. Plan Sponsors: Unlock The Power You Never Had Before

“Financial review with forecasting including actuary analysis is a critical element forming the foundation upon which our risk management services are based. Without actuarial analysis a plan sponsor cannot be certain recommended risk management strategies will produce anticipated results.” – Bill Rusteberg

Forget Ozempic – Try This Instead

Lose weight the natural way.

By Bill Rusteberg

I met two young and attractive ladies, one from Cuero and the other from Hallettsville today at the Cuero Christmas Festival. There were crowds of people of all ages enjoying the music and festivities, meandering around the old downtown part of Cuero where historic buildings are located.

Preauthorization Turns Claim Paying Policies Into Premium Only Policies

Everyone hates it when insurance companies second guess their trusted doctors. “What do you mean you won’t cover it! My doctor says I need the care!”

Innovative Texas TPA Strikes Gold

A Texas TPA uses an ingenious method to drive up their compensation levels. This strategy hinges on the ignorance of plan sponsors who know no better, particularly rural political subdivisions.

BUCA Renewal – The Story Behind The Numbers

How many people do you know that can keep a secret?

A BUCA renewal for a midsize, fully-insured case warned that the information contained in the re-rate calculation was CONFIDENTIAL and proprietary in nature.

Speaker Johnson May Start Trump Healthcare Agenda in End-of-Year Spending Package

The big PBM crackdown may be coming……………will politicians willingly give up campaign dollars?

Home Remedy For Hypertension

One of the oldest home remedies for hypertension is often found in dentist offices and hotel lobbies.

Litigation Update: Another Health Plan Lawsuit Alleging Mismanagement by Third Party Administrator

SOURCE: Haynes Boone – December 10, 2024

A recent complaint (“Complaint”) brought by Owens & Minor, Inc., in its capacity as plan sponsor of the Owens & Minor, Inc. Group Health Plan, a self-funded plan (the “Plan”), asserts that the Plan’s third party administrator, Anthem Blue Cross and Blue Shield (the “TPA”), breached its fiduciary duties to the Plan under ERISA. Specifically, the Complaint alleges that the TPA grossly overpaid certain medical claims on behalf of the plan sponsor and also pocketed pharmaceutical rebates that should have been paid to the Plan.

Musk Pitches Weight-loss Drugs to Lower Health Care Spending

Elon Musk, who is spearheading President-elect Donald Trump’s Department of Government Efficiency, is touting GLP-1 drugs to treat obesity.

Insurance for Organizations Who Make a Difference

Affinity Nonprofits

Aon Affinity Nonprofits is a brand name for the brokerage and program administration operations of Aon Affinity focused on the nonprofit sector. We specialize in developing, marketing, and underwriting customized insurance for nonprofit organizations.

Professional E&O Coverage

When you make a living off your expertise, you need comprehensive, cost-effective insurance to protect you financially from damages or legal costs that may arise.

Oscar Health CEO – “I Would Eliminate Employer Sponsored Health Insurance”

SOURCE: Finance / Yahoo.com

Oscar Health (OSCR) CEO Mark Bertolini sits down with Seana Smith, Madison Mills, and Anjalee Khemlani on Yahoo Finance’s Catalysts, addressing some of the various frustrations Americans have with the state of the US healthcare system.

Rx Gross To Net

By Christopher V. on Linkedin

What does “Gross to Net” really mean?

Yesterday I posted about the Assistant Secretary for Planning and Evaluation – HHS report on the first two years of RxDC data.

Gross to net in plain terms refers to the difference between a drug’s list price (the sticker price set by the manufacturer) and the actual amount that is paid after discounts, rebates, and other price concessions are applied.

Phia Group Beats IDR Statistics

By Adam Russo

A recent Health Affairs study underscores the challenges health plans face in the Independent Dispute Resolution (IDR) process, with a win rate of just 13.5%. In stark contrast, Phia clients benefit from a remarkable 53% success rate in IDR outcomes, including wins and dismissals.

How To Avoid Making Uncle Sam Your Richest Beneficiary

By Ross Friend -November 2, 2024

I have had several clients pass away in the last 12 months and all with different “types” of beneficiaries, e.g. spouse, family trust, children, siblings, with varying degrees of planning efficiencies in distributing the client’s wealth. Poor planning or failure to update one’s intentions can and may lead to an unexpected outcome, i.e. ask the IRS. There is never a bad time to ensure the client’s assets are reviewed for the most efficient tax transfer and aligned with their objectives. The SECURE Act changed the retirement and estate-planning landscape and you need to be aware of the tax efficiencies available whether you are a surviving spouse or not.

Diagnosing Vital Signs

“Please step on the scales” says the harried nurse assistant followed by “Have a seat and let’s take your blood pressure and temperature.”

Meakin Metabolic Care

MMC offers comprehensive and evidence-based metabolic care to all patients, with a specialized metabolic program tailored for cancer patients to complement conventional treatment.

MedSave Health Plan

“The first $8,000 is on me. The next $8000 is on you. Everything above that is back on me” said the employer. “Whatever you don’t spend of the first $8,000 is yours to keep.”

Solving Health Care One Client At A Time

The Tyler Rose (on the left) and her partner have been described as “A force of nature.” If you’re an employer and don’t know them you should. If you’re a competitor and don’t know them you should fear them.

Gallagher to Acquire AssuredPartners for $13.45 Billion

9th December 2024

By Kassandra Jimenez-Sanchez

Arthur J. Gallagher & Co. today announced it has signed a definitive agreement to acquire AssuredPartners, a US insurance broker with client capabilities across commercial property/casualty, specialty, employee benefits and personal lines, for a gross consideration of $13.45 billion from GTCR.

You Remind Me Of Your Grandmother When You Smile!

Bad Handwriting Can Kill You

Health Insurance Is Cool Because…….

GLP-1 Weight Management For $250/Month

Blue Light Special – Order your Will Power Drug for only $250 per month, or $3,000 per year online without the hassle of spending hours away from work sitting in a germ infested waiting room of moaning, coughing, sneezing walking dead people.

ACA Sales Way Down This Year

By Sam Melamed

ACA sales continue to be way down this year compared to last and the numbers are fun to dig into for a data nerd like me. Some interesting angles emerge when analyzing the data that tell a pretty powerful broker story. The dataset compares FFM ACA sales and State based exchange enrollments this year vs last year and the data comes directly from CMS.

Elon Musk Questions U.S. Healthcare Costs Amid CEO Murder Investigation

Billionaire entrepreneur Elon Musk has sparked fresh debate over the value of the U.S. healthcare system, calling for Americans to get “their money’s worth” after data revealed skyrocketing administrative costs.

Marpai 10k Report

The following excerpts are from Marpai’s SEC Q10 Report ending September 2024

“Based on our current financial condition, our Board of Directors, supported by our management team, is considering exploring strategic alternatives focused on maximizing shareholder value.”

4 Keys To Patient Navigation

By Eric Bricker

Learn from the experience of one of the original patient navigation companies: Compass Professional Health Services. I founded Compass with two other co-founders and together we grew the company to 1.8 million members across 2,000 employer clients over 11 years.