Archive for the ‘Uncategorized’ Category

Does BCBS Manage Claims or Do They Just Pay Them?

Sunday, November 19th, 2017

One of my arguments about Blue Cross is that they do not manage claims, they just pay them…..

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PPO “Discounts” Off Billed Charges Mean Nothing

Sunday, November 19th, 2017

 

A fascinating study by Alan T. Sorensen in 2003 on PPO discount patterns is an instructive read. The State of Connecticut’s data of the state’s hospital industry provided Sorensen a rare opportunity to study payer-level differences in negotiated discounts for hospital services and gives the reader insight into certain myths the managed care industry (including carriers, TPAs, agents and brokers) have successfully foisted upon clueless consumers for the past 35 years.

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83% Of Business Leaders Think Their Insurance Agents Suck!

Sunday, November 19th, 2017

Benefits represent a company’s second largest expenditure, yet only 17 percent of business leaders think their programs are being managed effectively…………..

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How One Insurer Makes A Fortune By Reducing Healthcare Costs

Saturday, November 18th, 2017

“The best way to lower health care costs is to lower health care costs”……………”Healthcare costs are directly related to what we agree to pay for healthcare”…………………..”The secret to lowering health care costs is to find providers willing to take less and discarding providers who want more – it’s called Free Market”…………. “If you want to cut your health care costs by 50% and more, without sacrificing quality or level of benefits, you can…………………”

The following article proves all of the above:

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Request For Proposals – Non-Disclosure Statement

Friday, November 17th, 2017

By Bill Rusteberg

Acting as a fee based insurance consultant in managing a formal, public Request For Proposal process requires adherence to certain guidelines memorialized in statutes pertaining to political subdivisions.

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HOLY BENEFIT MANAGEMENT, BATMAN!

Wednesday, November 15th, 2017
 
Employers are unhappy with their PBM relationships. Only one-third of employers rated their PBM as “very trustworthy.”

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TRS Care Marketing Opportunity for Insurance Agents

Tuesday, November 14th, 2017

As expected, there are many people leaving TRS and trying to secure a new health and drug plan in 2018……

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DOL Gives Kiss of Death in “Healthcare Madoff” Scheme

Monday, November 13th, 2017

By Mark Flores

The Complaint also alleges multiple violations of ERISA including, using plan assets to pay excessive fees and expenses, assessing undisclosed fees to the contribution amounts, failing or refusing to pay approximately $16 million for member’s medical claims, then transferring unpaid monies to offshore bank accounts in Bermuda.

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Veterans Day 2017

Friday, November 10th, 2017

 rusreberg

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.

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How Reinsurers Help Hedge Funds Shelter Taxes

Friday, November 10th, 2017

Zero tax rate attracts money offshore………………………..

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The Smart Plan

Friday, November 10th, 2017

QUESTION: What’s the opposite of “Smart?”

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Humana Profits Fall As Insurer Cuts 2,700 (Human) Jobs

Thursday, November 9th, 2017

Humana said the company is cutting the jobs in part to invest in technology………….…………

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County Continues To See Drug Savings Through Canadian Rx Mail Order

Wednesday, November 8th, 2017

The county continued to save money this year under its Canadian prescription drug program, county officials said Friday……

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‘High-Performance’ Health Innovators Could Improve Outcomes, Lower Costs

Tuesday, November 7th, 2017

Consider what might happen if you could, say, guarantee a benefits manager a 25% reduction over current healthcare spend, with better outcomes. That would be an offer that she couldn’t refuse, especially if her CFO heard about it.

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Confessions of a Reformed Health Insurance Broker – From Innocence To Darkness

Sunday, November 5th, 2017

Slowly we saw the rise of third party administrators, the evil purveyors of self-funded employee health & welfare plans…..

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WHY AN ‘OUTRAGEOUS’ $169,600 MEDICAL BILL ACTUALLY GOT PAID

Sunday, November 5th, 2017

OUTRAGED CONSUMER

Would you pay $169,600 for a $3,000 – $4,000 procedure? Well, guess what, you have already – it’s embedded in your health insurance premiums…………………..

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Cost Plus Rx Model For Self-Funded Health Plans

Friday, November 3rd, 2017

We bring you a network of independent pharmacies with a simple and unique pharmacy payment model. Our cost plus model reimburses drug costs via the nationally published public NADAC list and a fixed drug dispensing fee. No more arcane acronyms like MAC, AWP, and WAC and no more lengthy contracts detailing complex generic and brand definitions.

Editor’s Note: If you are in the pharmacy business I would like to hear from you – any comments or suggestions you may have I will post in a follow-up blog posting………….Rx costs are out of control and the PBM world doesn’t seem to care. Perhaps PBM’s are the bad guys? If not, convince me please………………Write to RiskManager@RiskManagers.us

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Blue Cross Blue Shield of Arizona PPO Rental Network

Thursday, November 2nd, 2017

Blue Cross Blue Shield of Arizona (BCBSAZ) provides large, self insured groups access to the BCBSAZ provider network……………..But how do they keep their PPO payment methodologies secret from the TPAs and more importantly, plan sponsors who pay the bills?

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The Deception Behind Those In-Network Health ‘Discounts’

Wednesday, November 1st, 2017

UnitedHealthcare  boasts that its PPO—a network of more than 780,000 professionals—cuts the cost of typical doctor visits by 52%, while saving 69% on MRIs. Pull back the curtain, and you’ll see these discounts are an accounting trick. To allow PPOs to advertise big discounts, providers simply inflate their billed charges on a whole range of services and treatments.

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Wellness Plans Face Scrutiny By DOL – Why Have One?

Tuesday, October 31st, 2017

Company Wellness Coordinators

Wellness plans don’t work. In theory they may, but in reality they don’t. Changing behavior is very hard to do, especially if it is societal and ancestral. 

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Free Health Insurance – Welfare (Subsidies) on Steroids

Tuesday, October 31st, 2017

The American Welfare State continues to grow. Proponents don’t call it welfare though. They call it “subsidies” instead. That’s a nicer, cleaner, less controversial term intended to calm frayed political nerves among those who work for a living and pay their own way. So when you read the following article, mentally substitute the term “subsidy” to “welfare.” 

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Prescription Care Management

Tuesday, October 31st, 2017

PCM saves 10-15% of total drug spend by utilizing therapeutic alternatives………….

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CVS-Aetna Deal Could Upend Future Role of PBMs

Tuesday, October 31st, 2017

“You are hearing the warning for the end of the road for the classic standalone” pharmacy benefit business…………………………”

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How Health Systems Are Like Newspapers

Tuesday, October 31st, 2017

“Hospitals are losing money on Medicare and Medicaid patients! They must charge commercial payers more to make up the difference!” is a much used argument to gouge consumers up to 1000 times more than what Medicare pays. Perhaps there are other contributing factors to hospital angst these days? 

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Why the Potential CVS Acquisition of Aetna is Brilliant………………

Tuesday, October 31st, 2017

The Law of Unintended Consequences……………Revenue enhancement through deception?

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TPA Caught “Working The Spread”

Sunday, October 29th, 2017

The settlement resolves a lawsuit in which the DOL alleged that the TPA breached its fiduciary duties and committed prohibited transactions when it retained and did not disclose “network management fees” consisting of the difference between amounts charged to plans and amounts paid to health care providers……………..

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Firm Offers Direct Provider Contracting for Employers

Saturday, October 28th, 2017

GM&A is a leader in direct contracting between employers and healthcare providers……

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Amazon Gains Pharmacy Licenses in Multiple States

Friday, October 27th, 2017

Throughout the past year, and without much fanfare, Amazon.com Inc. has gained approval to become a wholesale distributor from a number of state pharmaceutical boards, according to a review of public records.

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DisneyLand Buys Blue Cross & Blue Shield

Friday, October 27th, 2017

In an unprecedented move, the Blue Cross & Blue Shield Association announced this morning Disneyland has concluded talks with all BCBS plans in the United States and has reached a definitive agreement to purchase the Blues for $4.3 trillion. A spokesman for the BCBS Association has scheduled a press conference this afternoon to provide details.

In tandem with this blockbuster announcement was breaking news out of Chicago………

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PPO’s Are Dying

Tuesday, October 24th, 2017

PPOs are Dying – Why Pay for One?…………….Do you pay for a grocery store network…………?

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Working The Spread

Monday, October 23rd, 2017

The Weslaco ISD lawsuit against Aetna is a fascinating read. The pleadings provide clues for those who are curious about various revenue streams found (or not found) within some administrative contracts for third party administration of group medical plans.

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Getting Screwed

Monday, October 23rd, 2017

When it comes to hospital bills, you don’t get the itemized version of the bill, so you often have no idea what you are actually paying for………. (more…)

EDMUNDO O. RAMIREZ  – 1952-2017

Saturday, October 21st, 2017

Edmundo was a fighter. He fought hard for his clients and protected those he loved. He lived life on his own terms, and he died on his own terms. This rock solid, self-made man will be missed by many. 

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Slapped In Texas

Friday, October 20th, 2017

TPA Loses Lawsuit Against Private Citizen

“The Texas Legislature unanimously adopted one of the strongest Anti-SLAPP statutes in the nation and showed their continued support of the First Amendment.  On June 17, 2011, the Texas Citizens Participation Act (the “Texas Anti-SLAPP statute”) was signed into law by Gov. Rick Perry.”

“The statue allows a judge to dismiss frivolous lawsuits filed against one who speaks out about a “matter of public concern” within the first 60 days.  “Matter of public concern” is defined expansively in the statute.” (slappedintexas.com/primer/)

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Pile Makes Incredible Offer

Thursday, October 19th, 2017

“I’ll Make You An Offer You Can’t Refuse”

Can anybody use 5% of their healthcare spend back?? Give me a call so I can show you why there is 5% there and how we will find and recover it for you.

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Direct Pay (Cash Pay) Strategies Make Sense

Thursday, October 19th, 2017

By Bill Rusteberg

Direct Pay strategies, which I call Cash Pay strategies, has had a positive impact on a 400 life case we manage.

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Open Enrollment as Turd Polishing Season is Over

Wednesday, October 18th, 2017

For 20+ years, Open Enrollment has meant explaining to employees how they’re going to pay more and get less when it comes to health benefits……………………..

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TPA Promotes Reference Based Pricing Model – Guarantees No Balance Billing

Wednesday, October 18th, 2017

A TPA specializing in self-funding for small group plans of 100 employee lives or less offers a unique Reference Based Pricing model that includes the promise of no balance billing.

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Opioid Crisis Fueled By Drug Industry and Congress

Monday, October 16th, 2017

Whistleblower Joe Rannazzisi says drug distributors pumped opioids into U.S. communities — knowing that people were dying — and says industry lobbyists and Congress derailed the DEA’s efforts to stop it

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Insurance Consultants Are Biased

Monday, October 16th, 2017

mulebriar

“The last category of independent insurance consultants are those that are never comfortable outside their insulated environment. They like the warm and fuzzy feeling of staying at home in a loving environment with Mommy.”

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Largest Employer South of San Antonio Seeks Insurance Consultant

Sunday, October 15th, 2017

Brownsville Independent School District, the largest employer south of San Antonio, Texas is seeking an insurance consultant for the district’s self-funded employee health & welfare plan.

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Selecting a Third Party Administrator

Thursday, October 12th, 2017

By William 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.

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The Cost of Convenience

Thursday, October 12th, 2017

ppoo

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

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Express Scripts to acquire EviCore Healthcare for $3.6

Tuesday, October 10th, 2017

Pharmacy benefit manger Express Scripts will acquire medical benefits management company eviCore Healthcare for $3.6 billion, which will give the company an entry point into a growing market, the company announced Tuesday in a securities filing.

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Dendy Opines

Tuesday, October 10th, 2017

When people or companies live off of opacity, there is a problem as one never knows if they are being treated fairly or not” – Mike Dendy

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How One Of America’s Most Innovative Benefits Leaders Reduces Clients’ Healthcare Spending 20%

Monday, October 9th, 2017

David Conterno

When the industry goes to higher deductibles, we remove them. When the industry goes to narrow networks, we remove networks. When the industry goes to narrow formularies, we expand them. When the industry invests in specialty care and surgical centers, we invest in primary care. When the industry looks to bring in more insurance products, we bring in less. Instead of increasing obstacles to getting any and all care, we need to be removing all obstacles to getting the right care.”

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Risk Tolerance & Reference Based Pricing Strategies

Sunday, October 8th, 2017

By Bill Rusteberg

Plan sponsors must recognize change brings risk and reward and understand doing nothing brings risk too. So what’s the difference?

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Over 1/2 Of New Cancer Drugs Show No Benefit For Survival or Wellbeing

Saturday, October 7th, 2017

Of 48 cancer drugs approved between 2009-2013, 57% of uses showed no benefits and some benefits were ‘clinically meaningless’, says BMJ study…………………

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Is All Preventive Care Screening Cost Effective & Prolong Life?

Saturday, October 7th, 2017

Physician Joins Witness Protection Program?

“We knew for years that if a patient is a smoker the risk of lung cancer is high.   So why did we not have annual chest x-ray as a screening tool? ” (Name Withheld) M.D.

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4 Texas Hospitals Pay $8.6 Million Over Kickback Allegations

Friday, October 6th, 2017

“Why Didn’t I Think of This!

Bernie Madoff

“If not for this kickback arrangement, the four hospitals would have been financially responsible for the patient transports at significantly higher rates………………..”

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How 2 Math Grads are Disrupting the Auto Insurance Industry

Friday, October 6th, 2017

Insurance industry continues to be rocked by innovative upstarts. This time disruption is not confined to health care, it is encroaching upon the property & casualty industry too…………..

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Association Health Plans: A Favorite GOP Approach To Coverage Poised For Comeback

Friday, October 6th, 2017

Under association health plans, small businesses can join associations — based on certain types of professional, trade or interest groups — that offer insurance to members.

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America Is Surprisingly Reliant on Foreign Medical Graduates

Friday, October 6th, 2017

Recent Foreign Medical Graduates Seek Internship in USA

By any objective standard, the United States trains far too few physicians to care for all the patients who need them. We rank toward the bottom of developed nations with respect to medical graduates per population………………….

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Trump Set To Roll Back Birth Control Mandate

Friday, October 6th, 2017

The Trump administration is poised to roll back the federal requirement for employers to include birth control coverage in their health insurance plans, vastly expanding exemptions for those that cite moral or religious objections……………….

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Moonbeam Ponders Signing Drug Transparency Bill

Friday, October 6th, 2017

“If it gets signed by this governor, it’s going to send shock waves throughout the country…..”

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Employer’s Health Care Congress 2017

Thursday, October 5th, 2017

Jeff Bernhard, President of Continental Benefits

This revolution is happening faster than I would have ever thought.  If you are a consultant and not sharing creative TPA options at this time, you will likely lose to a competitor consultant.”

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Self-Insurance Plan Could Save Idaho $13M, Consultant Says

Thursday, October 5th, 2017

A new analysis on how much Idaho would save by switching public employees to a self-insurance model puts the amount at $13 million for the first year of operation……….

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Health Care Networks of America – Restoring Physician Prosperity!

Tuesday, October 3rd, 2017

“Don’t Miss 70% – 85% of Billed Charge Reimbursement Rates!” touts Health Care Networks of America (HNA).

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Monday, October 2nd, 2017

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.

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Unique Defined Contribution Plan for Voluntary Benefits

Monday, October 2nd, 2017

What if a plan existed where employees could get what they wanted regardless of their health status and regardless of group participation requirements?

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Employer Healthcare & Benefits Congress

Monday, October 2nd, 2017

The Employer Healthcare & Benefits Congress (EHBC) brings together attendees from across the world to discuss the latest developments in employee benefits industry, from corporate health & well-being programs and the latest in healthcare reform, to trends in voluntary benefits and self funded insurance, the EHBC has the information you need.

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More States Looking to Section 1332 Waivers

Sunday, October 1st, 2017

States can apply for a federal waiver “to implement innovative ways to provide access to quality healthcare……” Does that include Reference Based Pricing strategies?

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The Monty Hall Problem

Sunday, October 1st, 2017

The Monty Hall Problem is an interesting study of Probility & Combinatorics. Actuaries among us will enjoy this short video………………………

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Who Starts Tyrone’s Car In The Morning?

Saturday, September 30th, 2017
Pssst………..Tyrone Is At It Again Godfather!

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Blue Cross Blue Shield of Texas Validates Reference Based Pricing Strategies

Saturday, September 30th, 2017

Blue Cross has successfully hijacked the term Reference Based Pricing  –  a damn smart marketing move……………………

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Balance Billing Is A Plan Sponsor’s Best Friend

Thursday, September 28th, 2017

jet

By Bill Rusteberg

“Balance billing only occurs when purchasing  goods or services without asking  the price.”

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Article Reveals More Than Headline

Thursday, September 28th, 2017

“The provider network is probably the biggest thing we think about,” said Kristine Grow, a spokeswoman for the industry group America’s Health Insurance Plans…………

Editor’s Note: This article is entitled one thing, but moves down multiple rabbit trails. The quote above for example illustrates the status quo mindset of many Americans mired in the quicksand of PPO networks. Then the article goes into “subsidies” which of course is just a politically correct word for welfare, or Americans on the dole. It seems to this reader the intended thrust of the article is focused on welfare payments to offset the cost of health insurance…………..Another massive transfer of wealth and America’s continuing  move towards socialism………….

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TRS Feeding Frenzy in Full Swing

Wednesday, September 27th, 2017

Over the past few months I have been telling you about the TRS Care health and drug plan changes coming 1-1-18.

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Hospital Costs Flat – But Plan Sponsors Don’t Benefit

Wednesday, September 27th, 2017


Michael (Mike) DendyCEO/Vice Chairman AMPS Inc.2h

Hospitals are charging 5, 6, 7 times more than they were charging ten years ago. This drastic increase in billed charges must be at least partially due to hospitals’ cost of doing business increasing, right? Wrong.

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ObamaCare Endures – Big Government Wins

Wednesday, September 27th, 2017

A dysfunctional Republican party breaks promise to repeal ObamaCare.

Tight government control and oversight of 1/5 th of the economy continues. Citizens will continue to be punished if they refuse to purchase health insurance……………….Individual freedom is eroding away bit by bit in this country.

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Medical Trend

Tuesday, September 26th, 2017

By Bill Rusteberg

Medical trend (inflation) is largely due to inflated medical costs guaranteed to increase year after year in managed care contracts through annual escalator clauses (Escalator Clauses, Rising Prices, And Why We Should Care). In addition, renegotiated contracts effectively cause a double whammy (renegotiated provider contracts always end up costing more, not less).

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Latest So Called “Repeal Bill” Cuts Off All ACA Funding After 2026

Monday, September 25th, 2017

A dysfunctional Republican party has yet another “Repeal” bill that contains provisions likely to be repealed (again) over time as the unified, “take no prisoners” Democrats gear up to win back the House in next year’s mid-term elections…………………..This newest feeble version maintains the government’s control of 1/5 th of the American economy and gives more power to bureaucrats…………

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Amazing Stop Loss Insurance Statistics

Sunday, September 24th, 2017

Kaiser Family Foundation Employer Health Benefits Survey on stop loss insurance highlights some interesting statistics…………..

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Got You Covered

Saturday, September 23rd, 2017

Do you have fan belt insurance? How about flat tire insurance?

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Sullivan Appointed as Texas Insurance Commissioner

Saturday, September 23rd, 2017

Texas has a new insurance commissioner………………………..

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