Archive for the ‘Uncategorized’ Category

1st Year RBP Report Card

Thursday, August 22nd, 2019

A mid-size Texas employer went from a BUCA to a Reference Based Pricing plan last year. The benefits remained the same. However, a change was made in the way providers are paid.  In lieu of paying through secretive managed care contracts, the plan paid medical providers based upon a transparent reimbursement schedule tied to a percentage of Medicare allowable charges.

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How to Get Around ERISA Anti-Assignment Provisions

Thursday, August 22nd, 2019

“There are three possible ways for providers to avoid application of the anti-assignment provisions in plan documents.

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Texas School District Lowers Healthcare Costs While Improving the Quality of Care

Thursday, August 22nd, 2019

“Managing health care on a local level brings needed accountability to health care financing while providing improved access to care and higher patient satisfaction. The patient-physician relationship becomes more than just a ten-minute office visit; it becomes a true partnership.”  – Alex Zuniga

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Beginning of The End of Group Health Insurance?

Tuesday, August 20th, 2019

Will HRA’s replace group medical plans?

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$0 Investment Brings $2.4 Million Annual Return

Monday, August 19th, 2019

Is it true a South Texas Hospital system is buying up primary care practices to fatten up their cash cow?

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The ‘follow-up appointment’

Sunday, August 18th, 2019

For many people in medical debt, a trip to the emergency room leads to the courtroom


Wenzle Hufford, 76, uses a rope to tow his wife, Lucynda, with his motorized wheelchair in Kennett, Mo. Both have large medical debts. His legs were damaged when he was hit by a car; she has diabetes and heart problems. (Michael S. Williamson/The Washington Post)

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The Misconception of Risk Pooling

Saturday, August 17th, 2019

By Bill Rusteberg

As members of the +400,000 member TRS ActiveCare risk pool “The Power of Large Numbers” and “Economies of Scale” bring comfort to small Texas school districts . “We could not get comparable coverage on our own, much less at affordable rates” is the mind thought of school district officials throughout the state.

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San Antonio Suspends Paid Sick Leave Law

Friday, August 16th, 2019

“San Antonio has agreed to delay implementation until December 1, 2019. The stay will allow time for guidance from the Texas Supreme Court on the law’s constitutionality. In the meantime, San Antonio’s Paid Sick Leave Commission has agreed to work with business stakeholders to recommend changes in the ordinance to the San Antonio City Council.”

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Hospital Bills 1661% of Medicare

Friday, August 16th, 2019

Hospital billed charges total 1661% of Medicare. A typical PPO “discount” would be between the range of 50-70%. If the later, the hospital would be paid about 498% of Medicare. Plan paid 180% of Medicare. Hospital still wants more money. Plan sponsor says “Not in my lifetime!”

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The Cost of Convenience

Friday, August 16th, 2019

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Selecting a Third Party Administrator

Friday, August 16th, 2019

By William Rusteberg

With the growing suggestion that the BUCAs are inflexible third party administrators unwilling and unable to administer Reference Based Pricing plans and other strategies in the market today, more brokers are seeking new partnerships with independent third party administrators (TPA). An independent TPA can offer much more than a traditional carrier model.

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Thursday, August 15th, 2019
“Those trying the preserve the wildly under-performing and bankruptcy-inducing status quo healthcare system will do whatever it takes to try to thwart progress” – Dave Chase

Why Some Doctors Purposely Misdiagnose Patients

Thursday, August 15th, 2019

In his time at the hospital, from 1999 to 2007, his salary rose from$185,000 to $300,000, and he qualified for bonuses up to $220,000 if he met certain billing targets.

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Off The Record

Thursday, August 15th, 2019

By Bill Rusteberg

While visiting Washington DC last year on business, I ended each day with a short visit to Off The Record, a bar located at the Hay Adams Hotel across the street from the White House. This place is always packed with interesting people and I had occasion to meet a few of them. 

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Wednesday, August 14th, 2019

Texas and Colorado issue cease and desist orders to health care sharing ministry………

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Hospital Administrator Morphs Into Insurance Sales

Wednesday, August 14th, 2019

See hospital administrator morph into an insurance broker before your very own eyes…………….From Hospital administrator to power broker in under five minutes…..

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Health Insurance Choices Could Get Your Client Deported

Wednesday, August 14th, 2019

New immigration regulations leave coverage purchased with ACA subsidies off the list of positives.

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Brownsville ISD Insurance Commttee

Tuesday, August 13th, 2019

If you are a new era health insurance consultant this video will drive you nuts.

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To Save Money, American Patients And Surgeons Meet In Cancun

Tuesday, August 13th, 2019

A knee replacement surgery costs an average of about $30,000 at U.S. hospitals, but only $11,000 at Galenia Hospital in Cancun, Mexico.

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North Carolina Caves – Hospitals Win Big

Sunday, August 11th, 2019

“By spending millions of dollars to oppose us and by using cartel-like tactics, these organizations were able to convince most hospitals to boycott the State Health Plan,” said Treasurer Folwell. “If big hospitals could do this to their largest customer, just think what they can do to the individual average citizen or business.

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Private Payers Pay 2.7 Times on Average What Medicare Pays Hospitals

Sunday, August 11th, 2019

With the lid ajar on Pandora’s box, we are likely to see employer demands pegged to price transparency and more strategies built on provider prices.

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The Phia Group Launches Newest Service: Patient Defender

Sunday, August 11th, 2019

Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.

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Recent Health Plan Practices That Are Resulting in Underpayments to Providers

Saturday, August 10th, 2019

“Anthem is determining whether an outpatient MRI, CT scan, or PET scan is “medically necessary” based on where the service is performed.”

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Do Hospitals Charge More to Make Up for Low Government Pay?

Friday, August 9th, 2019

Answer: “NO”. Hospitals charge as much as they can get away with…..

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Risk Payment Models

Friday, August 9th, 2019

Risk payment models present a daunting challenge to the very cultural of medicine—for most physician practices. Physicians identify their practices as clinical enterprises more than businesses………………..

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Health Care Is Gobbling Up Your Wages

Thursday, August 8th, 2019

SOURCE: Axios

“In 1999, the average health insurance coverage for a family consumed 14% of the average household income …  By 2017, family coverage absorbed more than double that amount, to about 31% of take-home pay.

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Union Urges School District To Consider New Era Health Care Strategies

Thursday, August 8th, 2019
 

The Brownsville Independent School District, like many public schools across Texas, is facing mounting, crippling health care costs through their self-funded health insurance program.

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Destroying Relationships

Wednesday, August 7th, 2019

“What do you do for a living?” asks the neighbor. “I destroy relationships” replies the salesman.

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Oh Oh, Novartis Hid Manipulated Data

Wednesday, August 7th, 2019

Approved in May, the treatment’s price — set at $2.1 million — stoked concerns about the astronomical costs of potential cures for rare diseases and upset parents who initially could not get insurance coverage for the breakthrough treatment.

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The Power of Labor Unions In Addressing Health Care

Monday, August 5th, 2019

Once labor unions learn the truth about what’s driving health care costs and become aware of proven methods to reduce costs while improving benefits at the same time, they will become a powerful force for change.  

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Million Dollar Mike

Monday, August 5th, 2019

He makes millions, threatens to deprive teachers, state employees, retirees and their families of affordable health care coverage.

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Profiting From The Poor

Sunday, August 4th, 2019

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

Nonprofit hospitals pay virtually no local, state or federal income tax. In return, they provide community benefits, including charity care to low-income patients. In Memphis, Methodist Le Bonheur Healthcare has brought 8,300 lawsuits for unpaid medical bills in just five years.

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Innovative Defined Contribution Plan

Sunday, August 4th, 2019

Innovative Defined Contribution plan now available for groups of up to 99 employee lives. This could be a value add to small group health plans such as those available through Allied National (www.Alliednational.com) and others.

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HEALTH FUND REFUSING TO PAY FOR LIFE-SAVING DRUG

Sunday, August 4th, 2019

There is only one known cure for the disease……… however the drug, priced at $2.1 million, is too expensive and not covered by health fund……toddler has only one more month to receive a new drug that could cure him………………

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New Drug Costs $2.1 Million – A Plan Sponsor’s “Poison Pill”

Sunday, August 4th, 2019

“Specialty drugs account for about 1% of prescriptions but 95% of prescription costs.” A new drug approved this year will bankrupt health plans……………..Plan sponsors should carefully study their Rx formularies to determine if there are other “Poison Pills” lurking…….then take action.

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Tooth Fairy To File Bankruptcy?

Friday, August 2nd, 2019

Seven year old boy files Tooth Fairy claim…………….No-limit tooth provision to set record reimbursement rate……….Tooth Fairy spokesman hints at bankruptcy….. 

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Trump Administration, In Shift, Announces Plan To Permit Drug Importation

Friday, August 2nd, 2019

“These manufacturers would be able to use a new National Drug Code (NDC) in doing so, possibly enabling them to offer lower prices than are available under their existing distribution contracts…………………….”

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Managed Care (PPO) Prices May Be Secret No More Under Trump Proposal

Tuesday, July 30th, 2019

The end of PPO’s may be coming to an end sooner than we thought…………..

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School Gives Raises, Health Insurance Takes It Away

Sunday, July 28th, 2019

 

A large Texas school district recently approved an across the board 4- 4.78% pay raise. Or is that number really 1% before taxes? The difference goes to area medical providers in the form of higher health care costs memorialized within secretive managed care contracts crafted by third party intermediaries. If the district had taken better advice, they could have lowered their health care costs 15-25% without a reduction in benefits, thus giving their employees a significant raise this year. Other Texas school districts are doing just that………………..

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Doctors Hospital At Renaissance Flexes Political Muscle in Deep South Texas

Saturday, July 27th, 2019

“The hospital opened in 1997 and has recently become a force to be reckoned with”…………..Much has changed since the following article was written in 2009 and it hasn’t been an erosion of influence…..

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Fort Worth Projecting $11 Million in Healthcare Savings in 2019

Friday, July 26th, 2019

“Hospital systems are seen as the evil empire, and facility costs are seen as driving healthcare expenses,” Dickerson says. “So we tried to keep people from going to hospital system.”

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Watch Aetna, Blue Cross, United Healthcare & Independent TPA Give Their Sales Pitch

Friday, July 26th, 2019

The Brownsville Independent School District recently went out for Request for Proposals for TPA services for the district’s self-funded employee health plan. The four finalists include Aetna, Blue Cross, United HealthCare and one independent TPA.

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Medicare Provider Utilization & Payment Data

Tuesday, July 23rd, 2019

Mission Impossible Assignment for Plan Sponsors

Nothing is secret about health care costs although many third party intermediaries wish it so. Piecing all the data towards responsible stewardship of an employer sponsored health plan is not impossible. Reviewing managed care contracts is not impossible either. Once I was told I would never get my hands on a Blue Cross hospital contract. I did. – Bill Rusteberg

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End Surprise Medical Billing

Tuesday, July 23rd, 2019

“If Congress cannot address even obvious market failures in private health care, a federal takeover of our entire health-care sector will become that much more attractive.”

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Surgical Company Sees Big Money Opportunity In Texas

Monday, July 22nd, 2019

Each investment would be $15 million, with an estimated 30 percent return on investment each year for a decade……………..

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How The Eastern Cherokee Took Control Of Their Health Care

Monday, July 22nd, 2019

“It doesn’t look like a hospital, and it doesn’t feel like a hospital,” Kristy Nations said on a recent visit to pick up medications at the pharmacy. “It actually feels good to be here.”

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Middle Class Anger Over Health Care Costs At Tipping Point

Saturday, July 20th, 2019

American Health Care: If you’re poor it’s free, if you’re rich it’s affordable, but if you’re a middle class American you’re screwed.

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TRS Seeks TPA Services

Friday, July 19th, 2019

A quick read of the minimum requirements knocks out all TPA’s except the BUCAs. This will be a bidding war between Aetna (incumbent), Blue Cross and United HealthCare. Smart money is on Blue Cross. Sadly though, changing the logo on the I.D. card won’t solve the problem of runaway health care costs………….

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Is Texas Single Payer Government Health Plan Imploding?

Thursday, July 18th, 2019

The TRS ActiveCare program is a ticking time bomb for Texas conservatives and a point of light for Texas liberals. Unless it’s fixed quickly Texas will become a Blue State faster than a melting raspa in deep South Texas on an August afternoon.

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Texas Addresses Free Standing ER Price Gouging

Tuesday, July 16th, 2019

With the stroke of his pen, Gov. Greg Abbott signed into law some of the strongest patient protection laws in the nation to shield Texans from the financial pain and misleading practices of free standing emergency rooms, where patients face a more than 80% risk of being balanced billed.

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Why Hasn’t Texas Joined The Reference Based Pricing Revolution?

Tuesday, July 16th, 2019

In Texas, it’s almost impossible to bribe a public official as long as you report it.” That’s what political scientists call “legal corruption,” and it’s the rule by which Texas operates.”

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Feeling Lonely?

Tuesday, July 16th, 2019

Could You Be Supporting a Hidden Retiree Health Plan?

Tuesday, July 16th, 2019

A retiree health plan is when ex-employees are provided for or allowed to purchase health care through their former employer.

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Slapped in North Carolina

Sunday, July 14th, 2019

“Delay and Confuse” is one of the oldest tactics used by incumbents under attack. The North Carolina flirtation with Reference Based Pricing for their state employees is a classic example.

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Ortiz Joins RiskManagers.us

Saturday, July 13th, 2019

“Nola’s commitment to excellence and her dogged approach to problem solving fits in perfectly with our culture here”

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CarynHealth

Saturday, July 13th, 2019

When Mike Dendy is involved, it’s golden. Introducing CarynHealth……………

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Hospital Official Reacts To RBP- “Burn In Hell You Sorry SOB’s”

Friday, July 12th, 2019

Mention Reference Based Pricing to a hospital official anywhere and you may experience first hand a human meltdown unfold before your very own eyes……………….

“Burn in hell, you sorry SOBs. Your plan to cut payments to hospitals could possibly be the most moronic idea I have ever seen come out of state government, and since you retardicians have taken power, and that’s saying a lot………….poor people generally don’t vote for your party, so you want them to die.”

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Doctor On Demand Going Viral

Thursday, July 11th, 2019

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‘An Arm And A Leg’: The Full Story Of Insulin And Its Cost ― No Sugarcoating It

Thursday, July 11th, 2019

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High Cost Of Insulin Sends Americans To Canada To Stock Up

Wednesday, July 10th, 2019

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Knowing The Answer Before You Ask But Hoping Otherwise

Tuesday, July 9th, 2019

We’re going to start paying you less, are you in or out……..”

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Working The Spread

Monday, July 8th, 2019
A lot has changed since Insulin’s Inventor Sold the Patent for $1.

Inline image

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The Case of The Two Legged Stool

Monday, July 8th, 2019

The ACA is a naked command to buy an insurance product the government deems suitable,” Texas Solicitor General Kyle Hawkins argued in court papers.

“Bereft of penalties, the mandate now raises no revenue and therefore cannot by any conceivable definition be considered a tax,” he added. “Stripped of its tax status, the individual mandate is nothing more than an unconstitutional congressional mandate to purchase health insurance.”

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North Korea Reinsurance Broker Launches New Website

Monday, July 8th, 2019

North Korea’s “first” insurance, reinsurance broker launches new website

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Judge Shoots Down Association Plans

Sunday, July 7th, 2019

A federal judge has rejected the Trump administration’s rules for association plans………….

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Proposed Rules Would Affect Prescription Drug Plans

Sunday, July 7th, 2019

Since the passage of the ACA un-elected bureaucrats in Washington have been issuing regulations faster than a melting raspa on a deep South Texas afternoon in August. Now the focus is on whorehouse high prescription drug costs…………

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New Stop Loss Trademark Coined By Client

Friday, July 5th, 2019
“We show up with bells on our balls when you need us the most!”

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Final Rule On Health Reimbursement Arrangements Could Shake Up Markets

Thursday, July 4th, 2019

Ruling will fundamentally change the way employers provide employee health care benefits……..

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Foundational Concept of Managed Care Under Siege

Wednesday, July 3rd, 2019

Managed Care Castle Under Siege

If current proposals come to fruition, the issue of narrow networks or surprise billing will no longer be the consumers’ problem………providers could be left holding the bag if their ability to negotiate is undermined by disclosing rates to managed care entities …….the need to contract could conceivably be impacted and the foundational concept of managed care could break down.

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OBAMA CARE IN FOUR SENTENCES 

Tuesday, July 2nd, 2019

Is there a single soul who is surprised that an engineer came up with this?  The 10,535 pages of the Obama Care legislation reduced to 4 short sentences.

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State Passes First Third-Party Auditor Bill

Monday, July 1st, 2019

bill that some insurers lobbied quietly to quash made its way through the Legislature and was signed by Gov. Phil Murphy on Sunday.

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French Work Ethic Crosses Atlantic – Lands in New York

Monday, July 1st, 2019

“The French are on vacation more than they’re at work.” “They can’t wait to get laid off so they can live off generous unemployment.” “They have no ambition.”  – (secretsofparis.com) (more…)

Lawsuit Alleges Rx Price Fixing

Sunday, June 30th, 2019

Lawsuit alleges Rx price fixing – read Summary for a synopsis……………..

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Unintended Consequences?

Friday, June 28th, 2019

“340B is a well-intentioned drug discount program gone awry………..” Has the program departed from its statutory foundation?

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Senate Panel Makes Surprisingly Fast Work of ‘Surprise Medical Bills’ Package

Thursday, June 27th, 2019

“Members of the Health, Education, Labor and Pensions (HELP) Committee approved a sweeping measure Wednesday that tackles a range of big-ticket health care concerns.

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