Month: September 2025

“Pfizer is agreeing to provide some of their most popular current medications to all consumers at heavily discounted prices of anywhere between 50% and even 100%”

Drugs will be available for direct purchase online at a website run by the federal government. 

By Donavan Pyle

Commissions create the most obvious misalignment.

Paying a benefits broker a percentage of your premium is like paying your GC a percentage of total project cost—it creates a powerful incentive to drive up your expenses, not control them.

By Cristin Dickerson M.D.

I was reviewing my 87 year old mother’s medications yesterday, thryoid and trazodone and supplements, and had her call in her renewal for the thyroid while I was there. She was a few days early and the pharmacist told her insurance would not cover it yet.

I told her to ask for the cash rate and she was quoted $940. I said that is for the 3 month supply, ask for 2 weeks worth. She was quoted $127.

I said ask for the GoodRX price, she was quoted $14 for the “coupon price”.

My mom is super smart, was a National Merit Scholar, but could not have navigated this on her own, she would likely have just gone without the medication a while.

This is where Stacey Richter‘s recent theme of profiteering over trust kicks in. The pharmacist obviously could not offer the coupon price until she was asked to do so.

Are these over-expenditures by the Medicare population factored into fraud and abuse? I think they qualify as such.

Dentist wants to see a wholesale increase in the maximum payable by dental plans. Costs have gone up but most dental plan have limited annual maximums averaging $1,000. What does TRS Care dental plan offer compared to this one?

FY 2025 TRS ActiveCare report shows a 114.5% loss ratio (page 41).

Half of Your Health Insurance Premium is Wasted.

How to Get It Back Without affecting payment amounts to facilities or providers at all. …………Healthcare is broken, and we are going to show you how we have fixed it.

PBM expands from pharmacy into unified claims and full benefit administration

Moldy Mary, the woman who saved 200 million lives. 

A fight nearly broke out right there in the fruit aisle. The setting was a grocery store in Peoria, Illinois. The owner, John Scoutaris, prided himself on stocking fresh, healthy fruit. But that day in 1943, he found a moldy grapefruit sitting out. He quietly palmed it, then slipped away to dispose of it.

It took a year but Henry was determined to feel and look better. “No one wants to feel bad and look bad” says Henry. “So I decided to do something about it.”

A spousal carve-out is a provision in a group medical insurance plan that limits or excludes coverage for employees’ spouses if the spouse has access to health insurance through their own employer.

By Bill Rusteberg

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. The sales cycle is long.

Sep 26, 2025

Arthur J. Gallagher & Co. sued two former producers this week who left in May to start Cornerstone Risk Advisors.

By Julie Wasserman

Florida. Known as the “Horse Capital of the World”. Also known as the state to have the HIGHEST overpayment of hospital charges for Employer Sponsored Health Plans vs. Medicare.

100% tax based on what? A winter Texan crossing the border at Progresso clutching his bottle of pills is asked by the dower border patrol agent “How much did you pay for this?” to which the aging mid-west retired farmer from Iowa winks and says “Fifty cents.”

By Bill Rusteberg

I conducted a price check today in a small two prescription drug store town in central Texas. I had been getting the prescription at a third pharmacy in town but they closed their doors several weeks ago. The price there was $22.

“Readers digest version: if you try to bring in your own oversight, you’ll either face enough friction to give up—or pay steeply for the privilege. Whether the intent is deterrence, revenue extraction, or both, the result is the same.”

By Katie Palmer 

Hundreds of telehealth companies, concierge medical practices, and medical spas have over the last few years built huge businesses offering compounded versions of popular GLP-1 obesity drugs while branded versions were in shortage.

In more than 50 warning letters sent last week and published on Tuesday, the FDA took these health providers and companies to task for false and misleading claims about the compounded products they market. 

By Alan Goforth 

Primary care has been shown to improve health outcomes and population health; reduce health disparities; and save money. Despite these benefits, however, accessing primary care has become more difficult.

Study shows that compared with GLP-1 RAs, bariatric surgery was significantly associated with greater weight loss while saving approximately $11,689 in ongoing costs over 2 years.

SOURCE: 46 Brookyln

Early this week, we released our review of four months of brand drug list price changes and generic drug acquisition cost trends. With brand list price changes ranging from as low as a 76% decrease and as high as a whopping 1,224% increase, there were plenty of eyebrow-raisers in the report.

Joe Sixpack Wanted To Know: Is Participating In A Cafeteria Plan Worth It? “If I join the Cafeteria Plan I’m held hostage for a year. Is it worth it?” asks Joe.

By Nick Lease on Linkedin

What if you could lock in your healthcare costs for 3 years—while improving EBITDA and reducing fiduciary risk? That’s exactly what we help our clients do.

By Donovan Pyle – CEO, REBC, CHVP

The most dangerous yet. CFOs: have you seen this buried in your benefits broker’s disclosure forms?

One Bill is the smartest way to offer and manage supplemental insurance. This program brings together the administrative function of best-in-class supplemental carriers, each specializing in their specific product categories, in one place.

You’ve probably heard the old tale of the engineer who charged $10,000 for fixing a machine – $1 for turning a screw and $9,999 for knowing which screw to turn. But what many don’t realize is that this isn’t just a fable. The story is real – and the man behind it was Charles Proteus Steinmetz (1865-1923), one of the most brilliant, yet often overlooked, engineers in history.

Underwriting Results Of A Mid-Size Self-Funded Health Plan

NOTE: This article is dedicated to the memory of Charles Proteus Steinmetz.

Amazing things can happen when you pay attention. The graph above illustrates the results one can expect when a plan sponsor replaces an insurance consultant who wasn’t paying attention with one who does.

By Donovan Pyle – CEO, REBC, CHVP – Health Insurance Whistleblower & Author of “Fixing Healthcare: How Executives Can Save Their People, Their Business, and the Economy” –

Osceola Schools has saved over $40 million since they fired Gallagher and started getting unbiased advice.

“We thought we were in the clear with 0% tariffs, and now a month later they come back and actually start implementing IEEPA tariffs without notice…”

By Bill Rusteberg

Selection of a third party administrator (TPA) is crucial to the success of a self-funded plan. Criteria usually revolve around several factors including compatibility. Corporate philosophies of the employer and TPA should harmonize.

“As long as you are fully insured, you are doing nothing more that perpetuating this farce.”

By Cris Deacon

Trying to audit your own claims with UnitedHealth Group‘s UMR? Brace yourself.

SOURCE: Katie Amin

Yesterday, U.S. Representatives Beth Van Duyne, Claudia Tenney, and Kevin Hern introduced a new bill, the Small Business Health Options Awareness Act of 2025, which requires the Small Business Administration (“SBA”) to provide more outreach and information about the availability of ICHRAs as a means for small businesses to deliver health care coverage for their employees.  

By Molly Mulebriar

Over the years I’ve heard a multitude of HR directors and payroll staff members complaining about voluntary benefits and the extra work involved.

By Marc Gravely

Warren Buffett revealed the sinister reason he loves insurance: “Your customer pays you upfront, and you get to negotiate what you give them back.” Texas schools, cities and counties are getting crushed by this exact game.

Mike was a famous character back in the day. Neighbors came around for miles just to see him. Admission was 25 cents.

Jimmy, a famous actor you’ve seen but never heard of, was insured for $10,000 and died at age 20………

“Paxlovid has 44 severe drug interactions, contains an HIV drug with a black box warning, is toxic to the liver and kidneys, is poorly tolerated due to metallic taste, has a 20% incidence of rebound infection and costs $1700.”

Looking for an easy way to open doors with new groups? Allied National’s Guaranteed Issue plans make it simple. With no medical underwriting and streamlined enrollment, you can offer employers valuable benefits without the usual hurdles. It’s a fast, hassle-free solution that helps you win more cases, strengthen client relationships, and grow your book of business.

By Molly Mulebriar

Aided by local TDI licensed partisans Curative Insurance Company, led by Generalisimo Juan Bock, has captured as many as seven cities in the Lower Rio Grande Valley in a lightening strike that would have made Rommel blush with envy.

By Joe Sixpack

It started Saturday morning. Throbbing pain from the lower left molar. Horrible pain. On a scale of 1-10 it’s a 20. What should I do, there’s not a dentist in town that works on a Saturday. Besides, I don’t have a dentist anyway. Haven’t seen one in years.

A True Story That May Help Explain Why Some of Us Wait So Long at the Doctor’s Office?

I went to the doctor this morning for my 6 month checkup. I always try to make appointments the same time as the door opens at 8:30 so I don’t have to sit in the waiting room for long periods of time. But today’s visit was different.

SOURCE: NCQA

“Up to 60% of all ED visits remain non-urgent and potentially unnecessary” 

By Bill Rusteberg

“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.”

SOURCE: BillingNav – Health Plan Guardians

The No Surprises Act was supposed to protect patients from balance bills. And it does. But here’s the flip side: employers and plan sponsors are the ones footing the bill — and it’s getting expensive.

“Don’t go to a free-standing ER they won’t have what you need…….”

Total Administrative Services Corporation

As the nation’s largest privately held third party benefits administrator, TASC has a mission to improve the health, wealth and well-being of its customers, employees, and communities.

Ruling determines discrimination based on gender identity violates the sincerely held religious beliefs of association members …………

Newly minted dentist treats his first patient who is in immense pain.

Earn up to an extra $500,000 in 2025!

Our 2025 Individual & Family Markets Producer Bonus Program offers strong incentives for producers selling qualified health plans in the individual and family market.

There are six methods to quick access to basic health care needs in this country in lieu of waiting days and weeks to see a doctor:

Attention Employees! We are pleased to announce a new health plan starting next month. There are five options to choose from!

If you’re fully-insured your NSA IDR four-year tail is covered. If you’re self-funded it isn’t and accrued risk can be significant.

The year was 2025…………….

“Your group health insurance is going up this year but I have some good news! I was able to get some underwriting relief” purred the well dressed and attractive BUCA rep.

The Food & Drug Administration is not always right…………………..

“Why are drugs so high?” asked Uninsured Johnny………”Because people pay for them with other people’s money.'” said Mother Teresa………….”How do I get some of that Other People’s Money!” said Uninsured Johnny………………”Buy insurance” replied Mother Teresa

Here’s what it looks like visually, sorted from lowest to highest average 2026 monthly premium:

SOURCE: ACA Signups – Author: Unknown

2026 Rate Change Project

Every year, I spend months painstakingly tracking every insurance carrier rate filing (nearly 400 for 2025!) for the following year to determine just how much average insurance policy premiums on the individual market are projected to increase or decrease.

Why have a health plan that pays based on a percentage of anything when a significantly less costly indemnity plan will do?

For example, here’s a health plan that pays up to $4,500 per day for an in-patient hospital admission. On average, would this be enough in your state?

Our top agents are enjoying $100,000 to $500,000 in yearly commission income

Starring Adam Russo

Adam answers questions like “Why would a hospital balance bill a patient for $90,000 when they know the patient doesn’t have it? ……..Why do hospitals seek an Assignment of Benefits?…………….What’s the importance of IRC501r?..………Which TPA in the market is the best one?………….Who is David Adams?……….………..and more.

The rise of AI-powered tools based on machine learning and natural language processing means consultants are no longer the sole source of strategic analysis. AI can rapidly analyze vast datasets, generate insights, and propose recommendations that were once the exclusive domain of expert consultants. This shift threatens to reduce demand for traditional consulting services, especially routine tasks

Sep 04, 2025

BillingNav achieved a 66 percent win rate in No Surprises Act IDR disputes – nearly four times the industry average.

Here’s another hospital pricing arrangement showing billed charges no one ever pays, cash prices few can afford to pay, lowest minimum negotiated prices with anonymous payers and the maximum negotiated prices with more anonymous payers.

Bill requires hospitals to publicize payer-specific negotiated charges. Secret managed care contracts will be no more.

Kyra Wensley’s doctor fought to keep her on the injectable weight loss medication Zepbound, but Wensley ultimately had to switch to Wegovy, a different GLP-1 agonist, to meet her health plan’s requirements

“With list prices of roughly $1,000 a month, public and private payers are struggling to keep up with ballooning demand for GLP-1 weight loss drugs and in some cases are eliminating or restricting their coverage as a result.”

Government Expands Access to Health Insurance: Consumers to Gain Access to “Catastrophic” Health Insurance Plans in 2026 Plan Year

”When a patient offers their right to obtain benefits from their insurance, that assignment of benefits is in and of itself consideration in full, exchanged for services and treatment.  An assignment of benefits is thus not a form of access to consideration, and rather, is the consideration itself.” – Adam Russo

• NO Waiting Periods and NO Deductibles
• $5,000 Dental Plan (per calendar year, per covered family member)
• Large National PPO Network
• Implants Covered on Major Services
• For Individuals and Employer Groups of 2+
• Fully insured by – A.M. Best Rated Insurance Company

Need a tonsillectomy and adenoidectomy? If you go to Methodist Hospital, it will cost you over $17,000.

The uninsured rate is a staggering 29.7% in the most uninsured Texas metro.

McAllen, Texas, “the most expensive town in the most expensive country for health care in the world” also has the distinction of having the highest uninsured population of any city in Texas.

Plan Sponsor Rejoices…………………

Nothing says “fiduciary duty” like blindly approving a +20% renewal.

By Craig Gottwals – Sep 02, 2025

If your agent, consultant, broker, advisor, whisperer (or whatever title they title thye’re using this month to obfuscate how poorly our industry has performed) only talks to you about “buying insurance” or renting one of the bloated national PPOs, you’re wasting money and, quite possibly, failing your fiduciary duty to your plan.

FOR IMMEDIATE RELEASE
September 2, 2025

Contact: HHS Press Office

202-690-6343
Submit a Request for Comment

Trump Administration announces forthcoming changes to ease approval of physician-approved treatments and inform patients up-front of the most appropriate and lowest cost prescription drugs

A Fairy Tale Come True

By Bill Rusteberg

“PPO’s drive up costs!” said the new era benefits broker “Do away with them and you will be glad you did! Your savings will be something to write home about!”

Before you read further brace ourself……….Cash Isn’t King at the ER at this Texas hospital. Neither is Blue Cross.

By Bill Rusteberg

As a self employed insurance agent I’ve worked with hundreds of clients over the past 50 years, the result of calling on thousands more in prospecting efforts to gain more business. I’ve met all types of personalities, developing a skill few have. Understanding motivation, goals and interests is secondary to understanding moral and ethical values of those you strive to do business with.