Archive for the ‘Uncategorized’ Category

How Hospital Reimbursement Does and Does Not Work

Thursday, September 6th, 2018

Hospitals create chargemaster prices by multiplying the cost they pay for a product by 300 to 1200%. Another little hospital secret is what is called an outlier payment…………………….

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Anthem To Offer New Association Health Plan in Las Vegas

Thursday, September 6th, 2018

The Las Vegas Metro Chamber of Commerce announced Wednesday that it is partnering with Anthem Blue Cross Blue Shield to offer health plans to its members under a new Trump Administration rule that makes it easier for small businesses to collectively purchase insurance…………….

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Study Shows Hospitals Charge 479% of Their Cost For Drugs

Thursday, September 6th, 2018

Percentage of Charges Model – 50% Off Double The Price?

Hospitals are generally not paid 100% of billed charges; however, hospital outpatient
departments are routinely reimbursed as a percent of billed charges by commercial payers……

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Demand For Medical Debt Reduction Service At All Time High

Wednesday, September 5th, 2018

Medical debt is a problem for 39% of insured adults in this country. 1 in 8 of those are on the hook for $2,000 or more. For more than 20 years RiskManagers.us has assisted members by reducing medical debt. As more employers cost shift to their employees, demand for medical debt reduction services is at an all time high………………………………

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City Budget Hinges On Employee Health Insurance Price

Wednesday, September 5th, 2018

A Texas municipality, facing rising health insurance costs, puts annual budget on hold until employee health insurance costs are negotiated. Maintaining city services and the expense of rising health care costs at the same time is Mission Impossible. Will Tax Man come to the rescue………………………?

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MedZERO Launches in Salt Lake City in Partnership with Asserta Health

Tuesday, September 4th, 2018

Offers zero-interest funds for out-of-pocket medical expenses…………….

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Dialing For Dollars

Monday, September 3rd, 2018

They changed over my status to “self pay” which cut my $10,400 the bill by 55%…………..

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$76,000,000 Health Insurance Swindle

Friday, August 31st, 2018

A Con Victor Lustig Would  Have Approved

Lab billing jumped more than 22,000 percent from August 2017 to May 2018, from an average of $37,400 per month to about $8.5 million per month………………..

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San Patricio County Seeks Insurance Consultant

Thursday, August 30th, 2018

San Patricio County is seeking qualifications from licensed insurance consultants to assist the county with its self-funded employee health & welfare plan. Firms / individuals are invited to submit their qualifications for consideration in providing a proposal for this scope of work.

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A Hospital Giant Discovers That Collecting Debt Pays Better Than Curing Ills

Thursday, August 30th, 2018

Making Money Off Medical Debt

As Tenet and other hospital companies struggle to make money providing medical care, they are turning to the profitable and growing business of collecting debt…………….

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She Paid $3.47 for a Prescription Drug. The Retail Price Was 10,000% Higher

Thursday, August 30th, 2018

 The story underneath is more complicated,” often reflecting a “black-box negotiation process between drugmakers, insurers and the middlemen who haggle behind closed doors over how much money changes hands……………….

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Why Use PBM’s When It’s Cheaper Without Them?

Thursday, August 30th, 2018

Insurance copays are higher than the cost of the drug about 25 percent of the time, according to a study published in March by the University of Southern California’s Schaeffer Center for Health Policy and Economics…………..

Editor – The problem is pharmacists are under a PBM gag order and cannot advise patients when it’s cheaper to pay cash than to use their prescription drug card

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How I Made $1 Million In One Phone Call

Wednesday, August 29th, 2018

“How Sweet It Is……………….”

Making $1,000,000 has never been easier……………………..

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Texas Teacher Thought He Had Great Health Insurance

Tuesday, August 28th, 2018

This blog entry illustrates the crazy world of hospital pricing in this country. A Texas teacher insured through his employer by a major carrier thought he had good insurance. He doesn’t think so now.

See how Scott Bennett calculated the hospital’s actual cost associated with a billed charge of +$164,000 in five minutes (www.linkedin.com/feed/update/urn:li:activity:6440264900991426560

Then read the article below.
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Someone Moved The Cheese!

Tuesday, August 28th, 2018

Even as they look back on several years of steady growth and success, many owners of independent insurance agencies now find themselves at a crossroad where they are pressed to make critical strategic decisions about the future of their firms……………….

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Texas Hospital Operating Income Soars 448%

Tuesday, August 28th, 2018

Hospital’s net patient service revenue was nearly flat year over year, but its premium revenue grew 13.5 percent to $1.3 billion………………

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Texas Farm Bureau Applauds Gilsbar

Tuesday, August 28th, 2018

 

Never in our history has the administration of the program been as flawless, smooth and efficient as it has been since Gilsbar has been our third party administrator. Gilsbar’s ‘can-do’ attitude and willingness to go the extra mile in support of the health program are welcome changes to our experience of past years.” – Texas Farm Bureau

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Monday, November 12, 2018

Saturday, August 25th, 2018

 

What will Texas do to reign in health care costs for the public good. We may soon find out………….

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New Case May Set Precedent For RBP Lawsuits

Saturday, August 25th, 2018

Lawsuit highlights one risk associated with reference-based pricing models: balance billing…..

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CapRisk Consulting Group

Saturday, August 25th, 2018

Actuarial and Business Consulting Services

CapRisk Consulting Group brings a practical means of problem solving to all of your actuarial risk and business insurance matters. CapRisk is an independent consulting firm offering a unique combination of actuarial and business consulting services, assisting clients with local, national, and international interests.

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Shared Savings Programs Require Closer Inspection

Friday, August 24th, 2018

Shared savings programs entitle the health plan to retain a percentage of any savings generated by their focused interventions in a given area……………..

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PBM’s Take Fees of 31% on Generic Drugs

Friday, August 24th, 2018

Ohio’s Pharmacy Benefit Managers (PBMs) charged the state a “spread” of more than 31 percent for generic drugs – nearly four times as much as the previously reported average spread across all drugs, according to a new report by Ohio Auditor of State Dave Yost…………….

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Will PBM’s Become Extinct?

Friday, August 24th, 2018

Will pharmacy benefit managers (PBM) could go the way of the travel agent? After all, PBM’s function the way travel agents used to and benefit from price inflation………………………

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Man Made Pandemic Threatens San Antonio Employers

Thursday, August 23rd, 2018

 

Feared government mandate may lead to massive pandemic in Central Texas…………………

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Ruben Edelstein

Thursday, August 23rd, 2018

Ruben Edelstein practiced managed care in his own way……………………….

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Health Insurance Costs Pushing School District Towards Fiscal Cliff

Thursday, August 23rd, 2018

Steady increases in health care costs is one of the main forces driving this school district towards the proverbial fiscal cliff. Two school years from now, the district projects it will be spending $450 million more than it takes in…………………….

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How RBP Plans Can Easily Contract With All Providers

Monday, August 20th, 2018
By Bill Rusteberg
Through an innovative plan design, Reference Based Pricing (RBP) plans seeking to contract with local providers can do so quite easily.  It’s turning lemons into lemonade and it’s called an APO (All Provider Organization).

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Is Low Bid Always The Best Bid?

Sunday, August 19th, 2018

The science of how to compete against “low bid” is a discipline learned by losing. Over time a seasoned salesman will learn how to beat the “low bid” and win more than he loses.(How To Win Against A Competitor’s Low-Ball Price Bid – Forbes)…………….In the article that follows the “high bidder” who lost to the “low bidder” is protesting. Is the $700,000,000 savings really true……………….? Common sense dictates otherwise.

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Dirtiest Industry Secrets Exposed By Retired Insurance Agent

Sunday, August 19th, 2018

This anonymous agent reveals the dirtiest secrets of his profession, and the rules for building your personal safety net

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Telemedicine + Teachers = A+ Combo?

Sunday, August 19th, 2018
Niche marketing is a smarter way to quicker sales………………….

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How Much Did You Pay For Your Banana?

Saturday, August 18th, 2018

Imagine a banana in a supermarket.  It costs $1 for those paying with Visa, $3 for those paying with MasterCard, and $32 for those paying with cash.  You can’t sign up for Visa until you’re 65, and you can only get a MasterCard if you have a nice employer or a decent income.  Worse, customers have no idea that such price discrepancy exists.  They don’t even know how much they’ll pay for the banana until long after they’ve eaten it…………………

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Friends With Benefits Episode #9

Friday, August 17th, 2018

Jeff Bernhard and David Contorno interview  William Rusteberg on Reference Based Pricing

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Connecting Consumers With High Performance Medical Care

Friday, August 17th, 2018

It’s a fact that a huge variation exists in surgical quality by hospital. A hospital that has great outcomes in one type of surgery (such as orthopedics) may have poor outcomes for other surgery types (such as cardiac surgery or women’s health). Based on this, BridgeHealth created a program that connects members with high performance surgical facilities for their specific surgery type.

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Competitive Health Named to the 2018 Inc. 5000 List

Friday, August 17th, 2018

August 15, 2018 by Alex Mulvenna

IRVINE, Calif–August 15, 2018–Competitive Health, Inc., a leader and innovator in network and ancillary product solutions (CHI), today announced that it has been named to the Inc. 5000 list.

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Quality Is Not A Constant In PPO Networks

Thursday, August 16th, 2018

There are quality providers and poor quality providers. Why would you choose the later?

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Beware of Health Care Consultants’ Partnerships

Wednesday, August 15th, 2018

This article exposes a common practice in our industry and should be read by every CEO. Brokers and consultants earning undisclosed commissions through recommendations they make happens all the time. I see it and expose it but CEO’s don’t. Try showing some of them the evidence and see the reaction. 

Recently I was tasked in reviewing a 2,500 employee school district in Texas. Disclosed compensation to the Agent of Record was $128,000. Actual compensation was $614,000 shared by two brokers one of which the district never met or knew. What did the district do? They fired the brokers and hired a local broker to earn the $614,000.  –  Bill Rusteberg

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Blue Cross Hit With Flurry of ERISA Lawsuits – Again

Monday, August 13th, 2018

When are plan sponsors going to wake up? Hidden fees driving up health care costs are more common than you would think. But its true. We could name dozens of lawsuits filed over recent years exposing practices that would make your toenails curl up. Here is one example:Weslaco ISD vs Aetna Yet many plan sponsors look the other way and continue to fund the conspiracy…………………….

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Cutting Out The Middle Man

Sunday, August 12th, 2018

Have you ever wondered why healthcare spending is so high? We did. So we decided to peel back all the layers in the system and really look at where all the money was going. We were surprised by what we found……………………..

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The Attack of The Rebates (COMMISSIONS)

Saturday, August 11th, 2018

Health and Human Services Secretary Alex Azar has said Americans “do not have a real market for prescription drugs” because drug middlemen and insurers get a wide range of hidden rebates (COMMISSIONS) from drugmakers, but those savings may not be passed on to consumers or Medicare.

Editor’s Note: Lets not pretend any more. “Rebates” are simply “Commissions” paid to third party intermediaries to push drugs. Dressing up the English language like calling welfare “subsidies” and crippled “handicapped”, and queer “gay” may give a softer touch, but is it really necessary? The meaning is the same isn’t it?

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Defending The ACA Versus Enforcing The ACA In Texas v. United States

Thursday, August 9th, 2018

A potential upcoming preliminary injunction could block enforcement of the entire ACA or, alternatively, of the individual mandate, guaranteed issue, community rating, and preexisting condition exclusion ban provisions of the ACA………………….

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Are Employers Ready to Shake Up Health Care?

Thursday, August 9th, 2018

Frustration with the US health care system is mounting. There’s a disconnect between what we spend and what we get in terms of high-quality outcomes and a good patient experience. Employers have the power to change that………………………….

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Schuessler Highlighted in Employee Benefit Adviser

Wednesday, August 8th, 2018

Employee Benefit Adviser has just published an article this week listing the top social media users among insurance advisers across the United States. The usual suspects were listed, like Carl Schuessler the famed inventor of the ever so popular Schuessler Stick……………………………….

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Whistleblower Will Receive $17.2 Million From Overbilling Case

Monday, August 6th, 2018

A San Diego whistleblower will receive $17.2 million with the settlement of a 7-year-old false claims lawsuit against Prime Health Care regarding overbilling for Medicare services at 14 California hospitals.

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Guess Who Will Pay For Prime Healthcare Settlement?

Monday, August 6th, 2018

Passing along losses to consumers is one pen stroke away……………Will Prime Healthcare renegotiate their managed care contracts?

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David “Nostradamus” Contorno Reveals Amazing Prediction

Sunday, August 5th, 2018

David “Nosradamos” Contorno

I’ve hesitated to predict this publicly…but I am ready to now…………………….(Drum roll please)

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Specializing in Specialty Drugs: A New Middleman Steps In

Sunday, August 5th, 2018

Companies that negotiate for better prices on specialty drugs without the incentive of discounts and rebates…………………………..

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Trump Administration Exploring Idea of Importation of Drugs

Saturday, August 4th, 2018

It came as something of a surprise when Health and Human Services Secretary Alex Azar announced that the administration was exploring the importation of prescription drugs to fight high domestic prices……………………

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CEO Finally Realizes Health Care Was His Problem

Friday, August 3rd, 2018

“If you employ a workforce and offer benefits, your business IS a healthcare business” – Jim Immelt

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San Antonio Firm Saves on Specialty Drugs

Friday, August 3rd, 2018

San Antonio firm provides alternative source for specialty drugs with significant savings………

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Rx – Where Does All The Money Go?

Thursday, August 2nd, 2018

“[In] 2016, total US expenditures on pharmaceutical drugs, including the gross profits of all the intermediaries, were $480 billion … Two-thirds of this total ($323 billion) was captured by drug manufacturers in the form of net revenues. The remaining third ($157 billion) was retained as gross profits in the supply chain.

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TRS ActiveCare Announces Benefit Changes, Rate Increase 2018-2019

Thursday, August 2nd, 2018

The TRS Board of Trustees has adopted medical and pharmacy benefit changes to reduce a projected premium increase to 5.7 percent, instead of 7.2 percent. The main benefit changes were to add new freestanding emergency room (ER) copays and adjust specialist copays, deductibles and maximum out-of-pocket amounts.

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Two-Sided Transactions – How Will Supreme Court Decision Affect PPO’s?

Wednesday, August 1st, 2018

On June 25, the US Supreme Court issued a 5–4 opinion in a case that may have significant implications for health care……………….The case of the two-sided transaction………………

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Association Health Plan Regulation Face Challenges

Wednesday, August 1st, 2018

“The DOL acknowledged that AHPs will be MEWAs and that states will retain their existing authority related to MEWA regulation and enforcement….

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Trump Delivers On Promise of More Affordable Health Insurance Options

Wednesday, August 1st, 2018

Article Referred By Dan Meyland – Allied National

HHS announcement below – 12 month STM Contracts renewable for 36 months (details below)

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Medical Claims “Killing” Webb County Self-Funded Health Plan

Tuesday, July 31st, 2018

The following article appeared in the Laredo Morning Times almost a year ago. What has the county done since to address rising health care costs? From our vantage point, essentially nothing…………………

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Only One Election Away…………………

Monday, July 30th, 2018

Bernie & The Elephant In The Room

“If every major country on earth can guarantee health care to all, and achieve better health outcomes, while spending substantially less per capita than we do, it is absurd for anyone to suggest that the United States cannot do the same” – Bernie

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Centivo – A New Type of Health Plan

Monday, July 30th, 2018

Centivo, a New Type of Health Plan, Raises $34 Million in Series A Funding

Next Generation Self-Funded Health Plan Launched to Help Employers Deliver Affordable, Sustainable Healthcare for Their Employees.

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CMS Picks Fight With Powerful Hospitals?

Friday, July 27th, 2018

   THE COST IS TO DAMN HIGH!

The Centers for Medicare & Medicaid Services proposed significant cuts to the payment hospitals receive for care they provide to Medicare patients…………………

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Trump Officials Scoff at ‘Medicare for All’ Drive

Friday, July 27th, 2018

Medicare is running out of other people’s money, and those other people happen to be our children……

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50 Rural Hospital CEO’s To Know

Friday, July 27th, 2018

The CEOs featured on this list have overcome significant challenges operating rural community and critical access hospitals to lead sustainable and thriving organizations……………….

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.006 Cents On The Dollar Removes Medical Debt

Thursday, July 26th, 2018

Independent primary care providers donate over $10,000 to buy $1,474,987.25 in unpaid medical bills………………………….

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Health Care Maverick Hits The Airwaves

Wednesday, July 25th, 2018

Hello again everyone. I’m writing you all once again, but this time to share two radio appearances I made last weekend.

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ScriptSourcing: Ensuring Rx Access & Affordability

Wednesday, July 25th, 2018

Founded by CEO Gary Becker, a health insurance and risk management consultant for more than 30 years, ScriptSourcing works with employers to rein in the costs of Rx spending through a coordinated, seamless approach involving several key programs.

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The Cost of Convenience

Tuesday, July 24th, 2018

ppoo

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

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Some Texas School Districts Want Out of TRS ActiveCare

Monday, July 23rd, 2018

Since 2015, some El Paso school district employees and lawmakers have been asking the state to let them leave the program…………………………….

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The Health Care Payers That No One Has Ever Heard Of

Friday, July 20th, 2018

Go Away, I’ve Never Heard of Them!

What must we do when a patient presents an insurance card that lists no insurance company and no PPO network? We must reject them, the bible says so!

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School Teachers Are The Ones Paying For Health Care, Not Their Employer

Friday, July 20th, 2018

Teachers pay 100% of their health insurance, not their employers. How? Lower pay so the difference can be generously paid by the employer……………………………

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Do Hospitals Lose Money on Medicare?

Thursday, July 19th, 2018
Do hospitals lose money on Medicare? Google that and see all the articles that claim so and the few that say not. So what is the truth? Here is one expert’s view (which we share by the way)………….

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Doctors & Hospitals Sue Patients

Thursday, July 19th, 2018

Beware what you put on social media – you may be sued………………..

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Insurance Consultant Sentenced

Wednesday, July 18th, 2018

     William O. Haff

After more than three years in limbo, William O. Haff has finally learned his fate.

Haff has plead guilty to accepting bribes to steer his consulting clients to broker The Mullen Group. Sam Mullen of The Mullen Group has been given a prison sentence related to the scheme.

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U.S. To Make More Drugs Easily Available, Cutting Role Docs Play

Wednesday, July 18th, 2018

Americans may soon be able to get cholesterol-lowering medications and other widely used prescription drugs without seeing a doctor, a first step in what could amount to sweeping changes to how patients access treatments for chronic conditions…………….

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GROWDEN v. GOOD SHEPHERD HEALTH SYSTEM

Wednesday, July 18th, 2018

$25,308 Emergency Room Visit

Hospital sued for egregious pricing…………hospital responds by waiving all charges………Judge dismisses lawsuit…………Plaintiff appeals and wants to continue the lawsuit………….Appellate court agrees……..lawsuit continues……………..What is reasonable value of the treatment? Stay tuned……..

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HealthSmart® Launches SmartDecision™ Reference Based Pricing Solution

Wednesday, July 18th, 2018

The Reference Based Pricing movement is unstoppable. More vendors are entering the arena, moving away from managed care networks. HealthSmart is the newest entrant…………….

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Insurance Consultant Faces Sentencing

Monday, July 16th, 2018

William O. Haff

After more than three years in limbo, William O. Haff will learn his fate today before a Federal Judge.

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HHC Group

Monday, July 16th, 2018

As part of its broad suite of cost-containment services, HHC Group provides Medical Necessity (Bill) Reviews (MNRs) for Group Health, Auto and Workers Comp claims. Our Board certified physician specialists review medical records and billed codes to ascertain whether the services and supplies are appropriate and essential. They base their determinations on CMS and other nationally published and recognized guidelines (FDA, AMA, MCG, Cancer Institute, etc.). We do MNRs for all types of claims; prospective, post-service/prepayment and post-payment.

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