April 2025 – Risk Managers

Texas School District Seeks Cafeteria Plan Administrator

La Feria Independent School District is seeking a qualified Third-Party Administrator to administer its IRC Section 125 plan, benefits enrollment, and optional insurance program and 403 B compliance.

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.

Mike Reagan’s Drug Company

Mike Reagan, who has to be as old as I am (We both worked at the same BUCA 50 years ago), has found a living as a drug pusher.

Tonya Wins Big!

Watch Tonya H. win $10,000 for nailing a 94-foot putt on a basketball court during the Gatorade Golf Challenge at Bishop Ryan School.

Group Plan Drops PBM With Amazing Results

Why Use A PBM When You Can Do This Instead?

“We have no choice, it’s a moral issue” announced the company president during an Open Enrollment meeting. “We are not going to garnish your wages anymore for things you can’t afford!”

What Happens When Two Companies Merge and Then Scale Too Fast?

“Don’t worry, nothing is going to change!” said the company owner. “We are merging with another company who has the resources we need to do the things we’ve wanted to do but lacked the resources to do on our own.”

Don’t Feed The Beast

This book is about employer health plans and everyone who swims in that pond. It is a rare and valuable resource to help employers, advisors, direct primary care practices, direct specialty care practices, hospitals, networks and many others thrive in the model of free market healthcare.

The Love-Hate Broker Relationship

By Bill Rusteberg

TPAs and carriers find working with health insurance brokers a necessary evil although they will never say so out loud. To do so would be business suicide.

MedSave Management Partners With Dollar For

MedSave Management LLC is pleased to announce a new partnership with Dollar For to crush medical bills. This public service is completely free–no strings attached.

Free Hospital Financial Assistance Service

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

The Amazing World Of Artificial Intelligence Is Alive & Well In McAllen, Texas

By Bill Rusteberg

According to Atul Gawande McAllen, Texas is one of the most expensive health-care markets in the country. But it doesn’t have to be.

Guess What? Most Plan Sponsors Don’t Read Their Contracts

I once asked a County Judge (who happened to be an attorney) during a Commissioners Court meeting; “Judge, did you read the contract before signing it?”

How Mark Cuban’s Cost Plus Drugs Saved Us $490,000

A Six Minute Video Worth Watching……………….Growing evidence you don’t need a PBM to save money. It’s all about sourcing – some sources are better than others.

Plan Sponsor Alert: JPMorgan Chase Faces ERISA Class Action Lawsuit Over CVS Caremark’s PBM Practices

Following in the footsteps of similar lawsuits against Johnson & Johnson and Wells Fargo, employees of JPMorgan Chase filed an ERISA class action suit on March 13, 2025. The lawsuit alleges that JPMorgan, as the sponsor and administrator of its self-funded employee health benefit plan, breached its fiduciary duty by allowing CVS Caremark to manage the pharmacy benefits in a manner that enriched CVS Health and its subsidiaries at the expense of Plan members.

What’s Your Budget?

This morning, I hauled my aging tractor, of a brand no one has ever heard of, forty miles away down country roads no one ever uses to a town no one reading this blog has ever been to.

The BIG LIE

“We care about our valued employees. They are like family. We give them the best health insurance too. We have Blue Cross!” says the Human Resources Director.

Risk Managers Purchasing Cooperative

Risk Managers Purchasing Cooperative offers Participating Employers membership in a proprietary stop loss insurance risk pool designed to better manage their Benefit Programs’ stop loss risk.

Staying On Top Of The Market

Always good to know what’s out there in the market……………….

Here’s a plug for Curative Life Insurance Company. This Austin, Texas based insurance company is on a Blitzkreig across Texas, writing new business faster than a melting raspa in deep South Texas on an August afternoon.

Their no deductible, no copay, no out-of-pocket financial responsibility is hard to turn down, especially when rates are market competitive. Potential 2 year rate guarantees for groups that qualify.

The Great PPO Deception

“We have the best discounts! We will save you a lot of money! And you can’t do it without us because we have the buying power, you don’t! We are gonna gift you a 50% discount!” says the insurance company.

Insurance Corruption In Deep South Texas

By Bill Rusteberg

The Lower Rio Grande Valley in deep South Texas is known throughout the insurance community as a place where business can take one down the wrong road, purposely or not.

The Non-Profit Industrial Complex

By Dutch Rojas

Welcome to the Nonprofit Industrial Complex

Blue Cross Blue Shield Dice “NO MAS!”

BCBS of MA announces today, they will no longer cover GLP1″s for weight loss beginning on plan anniversary dates in 2026.

Financial Impact of Qzempic & Wegovy

GLP-1 medications pose such a great financial burden to employers that they may agree to a single-payer healthcare system run by the Government as a way of addressing the problem.

Executive Vice President of Insurance Brokerage Pleads Guilty in $133M Affordable Care Act Fraud Scheme

Friday, April 18, 2025 – SOURCE: www.justice.gov

For Immediate Release

Office of Public Affairs

A Florida executive pleaded guilty today for his role in a scheme to submit fraudulent applications to enroll consumers in Affordable Care Act insurance plans (ACA plans) that were fully subsidized by the government. The purpose of the scheme was to obtain millions of dollars in commission payments from the insurance company that operated the ACA plans. The federal government paid at least $133,900,000 in subsidies for fraudulently enrolled individuals.

The Largest Health Care Fraud Forfeiture In DOJ History

By Mark WeissMark Weiss

“David” Nourian was sentenced to 17½ years in federal prison—and ordered to forfeit $405 million. His crime? Running a kickback-fueled scheme that paid doctors millions to prescribe $15 compound creams billed at up to $16,000 per tube, mixed in the backroom by teenagers.

Ohio Medicaid Got Rid Of Big Middlemen, Paid Pharmacies More And Saved $140 Million, Report Says

By: Marty Schladen – April 17, 2025

Pharmacy middlemen working in Ohio on behalf of huge health conglomerates have long claimed they keep down drug costs. But a report released last week calls that into question.

Prescription Drug For Incurable Disease Lasting A Lifetime Costs $47,125 Per Year

You never know what a new hire will end up costing. Take the case of a new hire who started work June 1 of last year. She was on a $500,000 a year drug but the employer didn’t know it.

Texas School District Sits On A Ticking Time Bomb – The Spark May Be Their Health Insurance Plan

By Molly Mulebriar

A Texas school district is sitting on a financial time bomb and their self-funded health plan may provide the spark.

CostPlus Drug Company Partnerships

Erin L. Albert, MBA, PharmD, JD, DASPL

Here’s a list of PBMs we work with at Mark Cuban Cost Plus Drug Company, PBC.

Another Rojas Truth Bomb

By Dutch Rojas

The American Hospital Association doesn’t represent hospitals. It represents the right of health systems to keep their billing secrets, crush transparency, and sue your grandma without answering questions.

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

By Bill Rusteberg

Recently I was referred to a large medical group that was interested in learning more about how we help plan sponsors manage their employee health care needs. They were fully-insured with a BUCA and tired of double-digit rate increases year after year.

BLUE CROSS TX Blue Ribbon For Producers Program

“What are the chances your broker will recommend renewal of your Blue Cross plan this year?” we asked.

Half of Your Health Insurance Premium is Wasted and How to Get It Back

“At Sentia, our solution is to automate the entire health insurance process. We provide the Electronic Medical Records System (EMR) to practices, price the procedures 10% ABOVE medical consumer price index, and pay for work performed in real time. This eliminates medical coding, insurance networks, adjudication, rate negotiation, the cost of a third party EMR, all the big insurance buildings in every city in the US, and the millions of people that work at the insurance company that you, as the insured, pay for.”

Mark Cuban Says Health Insurance Shouldn’t Exist

“Why is the health of our entire country based on providers who don’t know their own fucking costs?” – Mark Cuban

GREAT NEWS For Employees With Spousal Coverage!

“If your spouse has access to coverage somewhere else, how would you like us to make that coverage into a 100% Health Plan with no out-of-pocket financial responsibility whatsoever?” purrs the nice HR lady. “We can make that happen if you agree to drop her off our plan!”

The True Version Of The Origin Of The Chinese Flu

“The WHO’s response to the COVID-19 pandemic was an abject failure because it caved to pressure from the Chinese Communist Party and placed China’s political interests ahead of its international duties.”

It’s Elementary My Dear Watson

By Josh Butler

Recently watched a City Council meeting from a city in the DFW metroplex. The presentation I watched was from a large brokerage firm who handles that City’s benefits. They were discussing the City’s annual renewal.

Fiduciary Duties In Pharmacy Benefit Management

Prescription Care Management Announces Latest Webinar April 23

MyHealthGuide Source: Prescription Care Management, 4/7/2025

RENO — PCM invites brokers, consultants, TPAs, health plans, and plan sponsors to join us for a timely and informative webinar addressing health plan fiduciary concerns. Presenters Chris Metcalf and Garret D’Antoni will guide webinar attendees through the complexities of fiduciary duties in pharmacy benefit management with practical, actionable insights.

Transparency Revolution: Executive Order Demands Actual Prices, not Estimates

Imagine holding, in your very own hands, a smart phone that can show you “actual” prices for any procedure at any hospital across the Fruited Plains. Imagine further that you can select any hospital of your choice, click a button and discover how much your health plan will pay and how much you will pay, if any.

Why Is Leonard Thompson’s 104 Year Old Miracle Drug So Expensive Today?

“In January 1922, Leonard Thompson, a 14-year-old boy dying from diabetes in a Toronto hospital, became the first person to receive an injection of insulin. Within 24 hours, Leonard’s dangerously high blood glucose levels dropped to near-normal levels.”

Texas HB 210 Cracks Down Conflicts of Interest In School District Contracts

Holy Smoke!

ICHRA Won’t Work For Us…..Our Employees Can’t Afford To Pay ICHRA Premiums Upfront!

“ICHRA Won’t Work For Us…..Our Employees Can’t Afford To Pay ICHRA Premiums Upfront!” We hear this a lot from employers who explore ICHRA as an alternative to their traditional group health plan.

Welcome to The Zebra Insurance Agency

Get personalized quotes in 5 minutes

Insurance is complicated, but it doesn’t have to be. While we’re famous for our online comparison tool, we also have a team of 100+ licensed agents dedicated to making insurance shopping simple and stress-free. With a mix of cutting-edge tech and expert know-how, we craft you comprehensive insurance solutions perfectly tailored to your unique needs, with no pressure to buy—just honest advice to help you find the best coverage at the best price.

Insurance Agent Contract Termination Language

The following contract language is not uncommon in insurance brokerage agreements:

Term and Termination. The Agreement will continue in effect until the earliest to occur of the following (1) either Party gives at least 30 days notice to the other Party of termination of the Agreement for convenience (which may be for any reason or no reason at all)…..

Trump Says ‘Major’ Pharmaceutical Tariffs On The Way

“President Donald Trump said Tuesday that pharmaceutical imports will soon be hit with “major” tariffs as part of his efforts to drive manufacturing back to the U.S.”

Have You Reviewed Your Termination Penalties Lately?

“We’re making more money now that they’ve terminated!” said the TPA owner. “Our runoff admin fees are triple and our PPO access fee changed to a percentage of the savings!”

ICHRA Blitzkrieg

By 2028, 24% of employer-provided plans are expected to be ICHRAs.

The Five Families of Healthcare

By Dutch Rojas

In every empire, there is a hidden court. A ruling elite whose power is felt but rarely seen.

Lowest Cost Drugs Is All About Sourcing, Nothing More, Nothing Less

You don’t need a PBM to find the best pricing. That’s not their model. You need something better. A better method to find the right price from a reliable source for every drug out there.

Dental and Vision for Individuals

You can sell dental and vision coverage to clients of all ages. We offer diverse dental and vision coverage to meet the budget and health needs of your single and family clients. With online enrollment and rates based on location instead of age, they are sure to find the perfect fit.

Group Health Insurance Isn’t What It Used To Be

“ For the first time in 40 years, I don’t have to worry about plan renewals, costs, outliers, stop loss, PBM’s and all the other crap……”

What did the Patient say to the PBM?

“I’d like my meds without the side effect of bankruptcy, please!”

By Michael Reagan, CBPA

Pharmacy Benefit Managers (PBMs) have faced criticism for practices that prioritize profits over the needs of patients, pharmacies, and payers.

South Texas FQHC – Providing Health Services Since 1971

Incorporated in 1971, Community Action Corporation of South Texas (CACOST) is a private 501 c (3) nonprofit with 53 years of progressive and uninterrupted experience providing high quality services to South Texans.

What Does A Direct Employer Contract With M.D. Anderson Look Like?

“It’s about as ugly as it can get” says a risk manager. “We don’t send people there anymore, their pricing is outrageous!”

It Didn’t! Yes it did! No It Didn’t. Yes It Did…………According to…………It Did! According to ………..It Didn’t

Question: Where did the Chinese Flu come from? Answer (A) No Such Thing, it’s a trick question (B) Basement at the White House (C) Chuck Schumer’s boyfriend’s Kitchen (D) Sacramento Water Supply (E) 4th grade experiment at Lincoln Elementary

Is Employer Managed Health Care Even Worth It?

“I don’t think the amount you save on tax free healthcare is greater than not overpaying on unit cost. Benefit advisors need to be doing this math to measure if an employer managing healthcare cost is even worth it.” Leon Wisniewski

Texas Lawmakers Consider ICHRA Tax Relief For Small Businesses

Texas lawmakers introduced legislation in March that aims to offer tax relief to small businesses that provide ICHRAs to their employees. Small businesses with between one and 50 employees would qualify for a refund of sales and use taxes or a tax credit against the franchise tax if they adopt an ICHRA and contribute a minimum of $400 per covered employee annually. The refund or credit amount would be calculated based on the number of employees enrolled in the ICHRA during the taxable year, with the credit capped at $400 per employee or the total amount of taxes paid under the sales and use tax system, whichever is less.

Bribery & Contracts of Adhesion

By Bill Rusteberg

Health insurance companies rely on independent insurance agents, brokers and consultants for market distribution. They compete for broker business by contractually capturing their loyalty through bribery and Contracts of Adhesion.

The Famous Hospital Gotcha Clause

Hospital Patients are Like Casino ‘High-Roller Whales’ – Hospital / Insurance Negotiation Explained.

The (artificial intelligence) Therapist Can See You Now

By Katia Riddle – April 7, 2025

New research suggests that given the right kind of training, AI bots can deliver mental health therapy with as much efficacy as — or more than — human clinicians.

Army, Navy, Marines, & Airforce Recruiters Flee Brownsville, Texas

BROWNSVILLE, TEXAS

The Army, Navy, Marines, and Airforce recruiters stationed in Brownsville, Texas are rumored to be packing their bags and heading out-of-state to greener pastures bringing panic to area residents.

New Era Health Plan Makes Sense

By Bill Rusteberg

The chart shown above illustrates the New Age of health care financing. The traditional role of the TPA is quickly becoming more of a fading memory than a value add.

Trump Administration Nixes Plan To Cover Anti-obesity Drugs Through Medicare

By TOM MURPHYUpdated 6:43 PM CDT, April 4, 2025Share

SOURCE: AP News

President Donald Trump’s administration has decided not to cover expensive, high-demand obesity treatments under the federal government’s Medicare program.

Mark Cuban: CEOs Should Create A New C-Suite Role

“Brokers are supposed to place the role of trusted advisor, offering expertise in making benefits and healthcare decisions, but …………”

Confessions from the Belly of the Beast

“I’ve spent the better part of three decades dissecting the American health insurance racket from every angle — as an attorney, as strategist, and as someone paid to clean up the mess insurers leave behind. I’ve seen it all.” – Craig Gottwals

Employer-Provider Direct Contracting: Practice And Policy

“Traditional TPA centered health plans, inefficient and expensive, are becoming outdated faster than a you can say ‘What Happened?’

“Payer platforms are emerging………….such as the partnership between Mishe Health and Mark Cuban’s Cost Plus Wellness, which allows real-time adjudication, flexible benefit design, same-day provider payments, and transparent contract management.”

TALON’s Universally Acceptable Payment Amount ™

“Forget the discount, forget the billed charge, we gonna pay you what we know you’ve accepted in the past. And we ain’t gonna pay no more stinking PPO access fees either!” – Molly Mulebriar

We Don’t Need The Highway Patrol Anymore Because Speed Limits Are Posted

By Craig Gottwals

“This is why telling employers they don’t need the legal muscle and case law precedent of Reference-Based Pricing (RBP) is like saying we can ditch the Highway Patrol — because hey, speed limits are posted now!”

The Rojas Insurance Coalition For Independent Physicians

By Dutch Rojas

After we sold Sano Surgery in the fall of 2022, I spoke with more than two hundred independent practices, including orthopedic groups, surgical centers, and a few physician-owned hospitals.

Each one had its own rhythm, with different EMRs, benefit plans, and ways of operating.

But they all had one thing in common: not a single one was working with other practices to coordinate their property and casualty insurance.

Offshore Rx Importation Exempt From Trump Tariffs

ScriptSourcing is pleased to share that pharmaceuticals and personal importation are exempt from tariffs. This decision allows us to continue supporting our clients in reducing prescription drug costs, which is crucial for improving healthcare accessibility. The exemption ensures that plan members can access essential maintenance medications with a $0 copay, significantly enhancing affordability and health outcomes.

Sincerely,
The ScriptSourcing Team

I Want To Go To MD Anderson!

A True Story

“I want to go to MD Anderson!” says Mary. “But they won’t take our insurance!”

The Fiduciary Survival Guide For HR and Health Benefits

Lawsuit Stuns HR Director – “What! We Have No fiduciary liability insurance!”

April 2, 2025 – BY Nikki Chambers – SOURCE: Nava Benefits

Summary

With rising regulatory scrutiny and an increase in class action lawsuits, fiduciary responsibilities in health benefits are more important than ever. This blog breaks down key fiduciary duties, common missteps, and practical steps HR leaders can take to protect their organizations and ensure compliance.

How To Get Fired By Asking The Right Questions (and get free food at the same time)

By Bill Rusteberg

How many plan sponsons read their PBM contracts? Or their BUCA ASO contracts? Or any of their health plan contracts?

Mark Cuban’s Health Plan Model

“The 1955 is a Point of Service Cash Pay Health Plan with a RBP wrap. No managed care network, no insurance company, no PBM, just a whole lot of common sense” – Don Pedro

“It’s just 1955,” Cuban said. “You see the doctor, pay them and that’s it. No fuss, no muss.” By paying Medicare rates or lower, Cuban’s contracts save money while ensuring transparency. All agreements are published, encouraging other businesses to adopt similar practices.

Rachel Decided She Could Do It Better So She Did

Rachel Means, The Second Best Insurance Consultant In Texas

“Our healthcare consulting business is built on fearless patient advocacy, efficiency, and attention to detail. So when we couldn’t find a Third-Party Administrator (TPA) that consistently met our high standards of care, we took action.”