March 2025 – Risk Managers

Capital Rx Unveils Healthcare’s First Unified Pharmacy and Medical Claims Processing Platform

New York, NY, Feb. 10, 2025 – Capital Rx, Inc., the enterprise health technology company and benefit administrator advancing our nation’s electronic healthcare infrastructure, is announcing Judi Health™, the industry’s first unified claim processing platform capable of administrating pharmacy and medical claims for employer plan sponsors, health systems, and health plans on a single platform.

Jeannine Sends PBM Into Shock

Jeannine Chiappini (Vice President, Benefits Consulting Practice Leader, Borislow Insurance) shocked us by revealing, “We are two years into the contract now, and we are at the point in our annual cycle where consultants are meeting with the schools [in the captive]… We are forecasting negative pharmacy trend for the schools. And we have a $30 PMPM savings versus two years ago.”

Mexican Dogs Get Better Deals

A friend runs a hunting lease in deep South Texas. I asked if rattlesnakes pose a danger to hunters. “Yes, could be, but not that prevalent. What you may find interesting is antivenom for my hunting dog who had an unfortunate up close experience with one was $700 but the same antivenom needed by one of my hunters was $20,000. Same drug. You ought to put that on your blog.”

Ivermectin Becomes Over-The-Counter Accessible in Arkansas

What’s the bid deal? We’ve been getting ivermectin over-the-counter at our local feed & seed store in Cuero, Texas for years!” – Bill Rusteberg

Ivermectin becomes accessible without prescription in Arkansas under new state legislation

Governor Sarah Huckabee Sanders has officially signed Senate Bill 189 into law, granting approval for the sale and purchase of ivermectin for human use without a prescription.

Supplemental Health Care Benefits

SOURCE: ArmadaCare

At ArmadaCare, we take great pride in forging new paths and redefining what insurance can be. We create supplemental health insurance plans that pay for routine and elective out-of-pocket medical expenses, not just unexpected ones. Having great coverage is only part of what makes us different – it’s also the built-in conveniences and support services that make our plans easy to use and highly valued.

Trump Announces “Medicare For All”

WASHINGTON: In an unprecedented and unexpected move today, the White House announced President Trump has signed a new Executive Order allowing private health insurers access to the Medicare network of participating providers.

Sorry, You Can’t Have It! It’s Proprietary!

“You have the legal right to demand access to claims, pricing, and performance data, even if the old contract says otherwise.”

WHY GOVERNMENT WON’T FIX HEALTHCARE

By Dutch Rojas

Those who imagine that legislative reform will cure America’s healthcare maladies suffer from a particular form of historical amnesia.

“Everyone Has To Kiss Their Ass….”

By Mark Cuban

Healthcare is a very simple business. We go to the Dr. The Dr tells us what we need (if anything). The ONLY questions are:
1. What does it cost
2. How will the patient pay for it

The Midas Touch

I’ve got an offer you can’t refuse! Free TPA administration plus I’ll pay you for the privilege!

By Bill Rusteberg

“Everything we touch turns to gold!” says the TPA. “That’s how we are able offer such low administration fees. We look real good on a spreadsheet!

Let’s Play I Spy

AUSTIN (KXAN) – A health insurance company managing the care of sick and disabled children in Texas faces accusations of spying on state lawmakers and private citizens.

A Better Way To Finance Prescription Drugs

Why pay $27,000 when you can get the same drug, same manufacturer, same packaging for $6,000? Why pay $5 to $10 in transaction fees for drugs that cost $1

DENTAL Care “Deserts”

By Dr. David Edward Marcinko MBA MEd CMP™

Dental care in America divides people into two camps: those who can afford regular preventive care and cleanings, and those who can’t.

Billy Says AI Will Replace Doctors, Teachers Within 120 Months

“Order Up Doctor Bill!” shouts Mary in her faded cap and gown. “Code Red!” screams the former school superintendent, “Coffee spill at Table 6.”

Meanwhile back at the factory, a former elementary school, the loudspeaker crackles, then in metallic monotone…………“Joe Sixpack report to the rec. room. The machine will see you now.”

You Are The Payer

By Ty Franklin

You are the payer. Yes, you, on the other end of this post…are the payer in healthcare. Not insurance (Insurance is the intermediary, middleman.) But you………It’s your money. Both directly, through monthly contributions and deductibles, copays, out of pocket maximums . and indirectly, through your company’s contributions…(aka the company is using your compensation to pay their portion).

NSA – Government’s Latest Healthcare Cure

The government’s Non-Stoppable Appointments (NSA) mandate is the best thing to happen to health care since Jesus cured the leper.

The $1 Trillion Wall Street “Tax” On The American Dream

By Dave Chase

Three ways of saying basically the same thing. Which do you like better?

There’s Margin in the Mystery

” If it costs roughly $1500/month to allow employees to fill these drugs through your health plan & PBM, but it costs about 1/3 of that to go direct, then…duh, I think you know the answer here.”

Tucker Carlson Drops Outstanding New Interview With LA Times Owner (and medical genius)

Dr. Patrick Soon-Shiong is a surgeon who made billions inventing cancer drugs. He says that Covid, and the vaccines that didn’t stop it, are likely causing a global epidemic of terrifyingly aggressive cancers.

Have An Insurance Adventure To Share?

Attention Insurance Men & Women! If you have an insurance adventure to share we will post it here.

Be Happy! I’ll Pay You 25% Above Cost!

Interesting article by Brian Norris. We are seeing a movement away from secretive managed care contracts towards old fashion free market economics long missing from American health care financing. The rise of consumer power in healthcare, driven by anger, frustration and financial distress will undoubtedly prevail – Bill Rusteberg

Predictors of High ER Utilization

By Eric Bricker

Predictors of High ER Utilization… 70% of hospitalizations begin in the emergency room (ER). Conversely, 13% of ER visits result in hospitalization.

The Future Of Health Care

You need to see a doctor and you need to see one NOW. Not tomorrow, or next week, or three months from now. You need to see one NOW!

Wegovy Manufacturer Screws Taxpayer Funded Health Plans

Patients enrolled in government-funded healthcare programs are not eligible for $499 cash price offer.

RISD Superintendent’s Insurance Company Settles Lawsuit

RISD superintendent’s insurance company settles lawsuit against Penitas

BY ALLEN ESSEX – Staff Writer – March 19, 2025

A Jan. 28 lawsuit filed against the city of Penitas by ESC-100 Executive & Consulting Services, LLC to collect unpaid fees for handling the city’s group medical insurance claims has been settled, said Gustavo Acevedo, attorney for the company.

The ACA Was The Greatest Piece Legislation Ever Passed?

“It was corporate statism, painted in the pastel colors of progressive compassion.”

Best Practices for TPA Evaluation, Selection, and Contracting

“A health plan’s fiduciaries are responsible for administering the health plan. Because most employers are not in the business of administering health benefits, they outsource the day-to-day health plan administration to a third-party health plan administrator (TPA). This outsourcing does not mean the employer is off the hook for their fiduciary obligations under ERISA. Even the evaluation and selection of a TPA is itself a fiduciary act, and employers must follow a prudent process.”

How Artificial Intelligence is Reshaping Health Insurance

“There is nothing permanent except change” – Heraclitus

As AI technology continues to evolve, its applications in health insurance will expand further. Insurers that embrace AI-driven solutions will gain a competitive edge…..

Marpai “Takes Decisive Action To Revolutionize Self-Funded Employer Health Plans”

MARPAI ACCELERATES HEALTHCARE TRANSFORMATION WITH EMPARA COLLABORATION, LAUNCHING UNIFIED HEALTH ENGAGEMENT PLATFORM

TAMPA, Fla., March 18, 2025 /PRNewswire/ — Marpai, Inc. (“Marpai” or the “Company”) (OTCQX: MRAI), a technology platform company and a disruptor in the $22 billion Third-Party Administrator (“TPA”) market, is taking decisive action to revolutionize self-funded employer health plans. Today, Marpai announces a strategic collaboration with Empara, a healthcare technology innovator, and an immediate rollout of Empara’s cutting-edge Health Engagement Platform.

70 Best Risk Management Blogs and Websites in 2025

The best Risk Management blogs from thousands of blogs on the web and ranked by relevancy, authority, social media followers & freshness.

“It’s Like Being On Crack!”

“A staggering 85% of people using GLP-1s primarily for weight loss stopped within two years. And almost all regained the weight.”

Oklahoma Insurers Scramble After Drivers Learn About Hidden Rebates

Oklahoma Drivers: You may be eligible to receive a massive discount on your insurance. New rules greatly favor those who drive less than 50 miles/day, and insurers are scrambling as drivers learn about this. Those who live in qualified zip codes can get even larger discounts.

550 Women Could Cost Texas State Health Plan $9,600,000.00

Texas legislators are considering gifting almost $10 million to pay for a new health plan benefit for approximately 550 plan members of the Texas state employee health plan. The “gift” is projected to cost 5% more each year due to medical inflation.

President Donald J. Trump Announces Actions to Make Healthcare Prices Transparent

EMPOWERING PATIENTS THROUGH RADICAL PRICE TRANSPARENCY: Today, President Donald J. Trump signed an Executive Order to empower patients with clear, accurate, and actionable healthcare pricing information.

The Mystery World Of American Prescription Drug Financing

Let’s assume the illustration above is true. What does it tell us about manufacturer average commissions (rebates) imbedded in their wholesale pricing?

Medical Insurance vs Confrontational Medicine & Back To The Future

“For some it’s hard to imagine the future, a future which is unfolding right now before their very own eyes. This future is yesterday in many respects except for one………..it’s better.”

Texas Reporterette Slants Reporting Against Free Market Choice

“How dare politicians take away health care benefits!” says the flower girl at Starbucks on Congress Avenue.

“Nothing of the sort!” says the cowboy stopping by to experience life on the other side. “Texans don’t have to buy the only health insurance they can afford. It’s their choice.”

Inside the Weiderhold v. AssuredPartners Complaint and Assured’s Alleged Motive to be “Opaque as Hell,” with Its handling of Client Rx Rebates

By Craig Gottwals

In this case, Alan Weiderhold alleges that AssuredPartners and its affiliates fraudulently concealed pharmaceutical rebate compensation owed to Plan Sponsors (employers who offer ERISA-regulated self-funded health plans to employees). Wiederhold was an executive at Evolution Healthcare (EVHC), a division of AssuredPartners, and claims he was wrongfully terminated for attempting to comply with legal disclosure obligations under ERISA (Employee Retirement Income Security Act) and the Consolidated Appropriations Act (CAA) of 2021.

A Health Plan Run By Doctors

This model is built around cost savings norms our physician partners have recorded. They are also well supported by independent analyses such as this one by the Society of Actuaries, or this one published in the American Journal of Lifestyle Medicine

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.

Solving High Cost Health Care Takes Unconventional Out-of-The Box Strategies

Solving the high cost of health care takes a team effort employing unconventional means towards a winning end.

Mail Order Specialty Pharmacy Touts Huge Savings

RightRx touts significant savings. How do they do that?

The Rise of Cash Pay Health Plans

In 15 minutes you will know more about Cash Pay Health Plan strategies than most Plan Sponsors.

The Fiduciary Obligation to Avoid 56,000% Markups on Rx

Lessons from the Latest ERISA Fiduciary Suit vs. JPMorgan

By Craig Gottwals

Imagine going to the pharmacy, filling your prescription, and trusting that your employer-sponsored health plan has negotiated a fair price for you. What if, instead, that same prescription was costing you hundreds—or even thousands—of times more than it should?

What Pharmacy Benefit Managers Do, and How They Contribute to Drug Spending

Role of a Pharmacy Benefit Manager in Providing Services and Flow of Funds for Prescription Drugs

* Includes establishing formulary and patient adherence programs and implementing utilization management tools – such as prior authorization, step therapy, and tiering — to steer patients toward certain drugs on formulary.

Data: Adapted from Congressional Budget Office, “Prescription Drug Pricing in the Private Sector” (CBO, Jan. 2007).Source: Kristi Martin, “What Pharmacy Benefit Managers Do, and How They Contribute to Drug Spending” (explainer), Commonwealth Fund, Mar. 17, 2025. https://doi.org/10.26099/fsgq-y980

Health Insurance Is Not Really Insurance Anymore

By Molly Mulebriar

Health insurance in the United States is no longer insurance in the traditional sense. It’s become an entitlement welfare scheme that’s fast becoming a heavily regulated government utility.

Calamity

Want to get into the insurance business? Here’s your chance……….

Medical Cost Comparison Shopping At The Click of A Button

The Power of Artificial Intelligence In Health Care Financing

AI is changing the world as we know it. For us we’re using it to lift the codes and prices from the medical bills and repricing it. This is much cheaper than owning/leasing claim adjudication programs and the human capital needed to operate these organizations (TPAs). AI allows you to take a picture of your bill and be done with it. The same transformation happened with buggy whip makers over 100 years ago. The automobile (ai) replaced how things used to work. That moment is now in the benefits industry. Next year or two it will be a lot smaller, cheaper, and less complicated” – Leon Wisniewski

ChatGPT, Please Provide A Cash Pay Health Plan Proposal

By ChatGPT

A Plan-Sponsored Cash Pay Health Plan is an alternative to traditional insurance that allows an employer to fund healthcare expenses directly, often leveraging cash pay discounts from providers. This approach can reduce costs while offering employees flexible, transparent pricing for medical services.

FDA Sued Over ‘Reckless And Arbitrary’ Semaglutide Decision

Article Referred By Tina Taylor

The Outsourcing Facilities Association (OFA), a Texas-based trade association focused on distributing compounded medications throughout the healthcare industry, has sued the U.S. Food and Drug Administration (FDA) for removing semaglutide from the federal drug shortage list.

Legacy TPAs Face Extinction

“Technology decisions can make or break a TPA’s ability to evolve, remain profitable and provide best-in-class service. But with legacy claims platforms, outdated member portals, and ongoing data issues, many TPAs are stuck or unsure where to focus next.”

The Rise of AI Powered Health Care

“AI is a transformative force reshaping how people engage with their benefits…….we are making benefits easier to use and empowering individuals with our AI-powered digital insurance wallets.”

PatientPAL

Many believe transversing the American health care system requires supportive Motherhood. PatientPAL serves that need………………..

The Rise of Self-Service Health Care

Back in the day …… “A car pulls up and out of the station spring four uniformed attendants who not only fill the tank, but check the tire pressure and oil and wash the car’s windows.“

Revolutionize Your Approach to Cash Pay Health Care Transactions

A Cash Pay Health Plan is easy to implement. You don’t need to pay exorbitant Care Navigation fees anymore when it can be done on a self-service basis with a click of a button.

Give Me Some Sugar!

By ChatGPT

Consuming sugar can have notable effects on both mood and energy levels. While sugar provides a quick source of energy, its impact on the body and mind is complex and can lead to both immediate and long-term consequences.

Plan Sponsors Don’t Need Stop Loss Insurance When They Do This

Nothing is forever. Not even a group health insurance plan. Cost has a limit. Sustainability is a constant.

The Great Statin Argument

“A long habit of not thinking a thing wrong, gives it a superficial appearance of being right, and raises at first a formidable outcry in defense of custom. But the tumult soon subsides. Time makes more converts than reason.” – ANONYMOUS

10 Drugs Poised To Be Best-Sellers In 2026

Article Referred By Jeff Barnhard

Four of the 10 medications Statista anticipates will yield the largest sales in 2026 are GLP-1 medications, according to data shared with Becker’s.

Texas Senate Passes De Facto Mandatory Diabetes & Weight Loss Program

““When I grew up, it was eggs were bad for you and steak was bad for you, right?”

Attention Plan Sponsors: ACA Compliant Health Insurance For Dependents

Employer paid health insurance is a great benefit. The problem is most employers don’t pay for dependent coverage. That’s a problem.

Lawsuit Alleges Insurance Brokerage Hoards Rx Rebates

“EVHC’s business model is based on hoarding rebates from PBMs, the complaint alleges. It states that in 2024, 61% of the company’s revenue came from rebates.”

Dallas-Area Pharmacist Sentenced To Prison In $145 Million Health Care Fraud

Untrained teenagers were mixing prescription creams, which were billed for thousands of dollars.

By Sarah Bahari

A North Texas pharmacist was sentenced to prison for a scheme to defraud the federal government out of millions of dollars for skin creams.

Want To Cut Admin Waste? Cut Out The TPA

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson

South Texas Politics – A True Story

“You are short sighted. When the new board gets in you will regret this.” – TPA

Diabetes 2 Remission Program

Heuro Health’s Type 2 Diabetes Remission Program For Employers

Rebates Lower Cost

An American industrial complex adopts an innovative method to turbocharge profits for a slew of intermediaries while making consumers believe they are getting the best bang for their buck.

Why Would A Plan Sponsor Not Do This?

Armando Polanco sent this to us today along with a note: “I recently ran the attached report for a group and still waiting to hear from them.”

The Rojas Report

Go HERE to see the first episode of The Rojas Report – Exposing the racket. Breaking down the business of healthcare.

In Rural Texas, a Measles Outbreak Hasn’t Swayed Vaccine Skeptics

She says she is against vaccines in general and scoffs when asked about the Covid-19 vaccine………………..“This is West Texas,” Romano says. “We don’t believe in that.”

Wisniewski Genius At Work

By Leon Wisniewski

I am pleased to tell you that we have successfully built an AI model to extract the procedure codes and pricing information from medical bills.

87% Of Americans Are On Government Funded Health Insurance

Those who argue against a single payer system ignore current realities.

How PBMs Make Money: PBM Practices & Profits

SOURCE: RxSafe

Growing awareness about the problems and pitfalls with pharmacy benefits managers (PBMs) in the US healthcare system has taken hold in recent years. Originally contracted by insurance carriers to negotiate on their behalf with pharmaceutical companies, these “middlemen” have hijacked the prescription drug marketplace to the detriment of pharmacies and patients.

When People Say “Why Is Healthcare So Expensive?” Show Them This Graph

By Chris Barakat – First Primary Care

Just remember. When people ask why is healthcare so expensive? And why are hospitals going out of business? Show them this graph.

Oxbridge Health Disrupts Texas Healthcare Market

Oxbridge Health Disrupts Texas Healthcare Market with Innovative Episode Benefit Plans for Self-funded Employers

MyHealthGuide Source: BusinessWire (full text), 3/5/2025

NORWALK, CT – –Oxbridge Health, an industry leader in episode-based healthcare solutions, announces its entry into the Texas market with Episode Benefit Plans designed to transform how self-funded employers provide healthcare benefits. These plans offer a compelling alternative to traditional health insurance programs, featuring more than 50,000 unique episode care groups statewide with full price transparency and the freedom for members to choose any physician or hospital.