Archive for the ‘Uncategorized’ Category

BenefitMall

Sunday, November 18th, 2018

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Merloch Coins New Term For Reference Based Pricing

Sunday, November 18th, 2018

Michael Meloch, President of TPAC Underwriters, comes up with a new term for Reference Based Pricing in a Phia Group podcast…………………………..

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Blues Plans Enjoy Record Profits

Saturday, November 17th, 2018

Blue Cross Blue Shield plans have collected billions of dollars in profit in the first six months of this year………………………….Premiums have vastly outpaced the claims that the health insurers had to pay out to hospitals and doctors……………..

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Pfizer to Raise Prices on 41 Drugs in January

Saturday, November 17th, 2018

   “Drug Costs Are Too Damn High”

As long as consumers purchase drugs with other people’s money big pharma knows consumer (market) blow back from pricing increases will be minimal……..

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Allied National Returns Unused Claim Dollars To Clients

Friday, November 16th, 2018

Allied National’s Funding Advantage contract returns unused claim fund dollars to employers who have favorable claims experience!

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I’m A Reformed Broker – Having Second Thoughts Is Not Possible…………

Wednesday, November 14th, 2018

Making $2 million on an 8,000 life Texas school district is really easy. I know because it’s been done, even as we speak…………………..

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AWP – Ain’t What You Pay

Wednesday, November 14th, 2018

INSIDE AWP: THE ARBITRARY PRICING BENCHMARK USED TO PAY FOR PRESCRIPTION DRUGS

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One Man’s Experience with Free Market Medical Care in the U.S.A.

Wednesday, November 14th, 2018

What’s ironic about this story, is this is exactly how we’d do it if our dog needed knee surgery…….

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Battle For Patient’s Wallet Moves To EHR

Wednesday, November 14th, 2018

“The only party not taken into consideration is the employer who is on the hook for the vast majority of the cost of drugs that will be sold through this channel……………….”

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Providers Push Back – N. Carolina Treasurer Pushes Back Harder

Tuesday, November 13th, 2018

“It doesn’t matter who the governor is, or who controls the legislature. It’s not political. It’s mathematical.”

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Jury Hits Aetna With $25 Million Judgement

Monday, November 12th, 2018

“Aetna pays its ‘medical directors’ bonuses for increasing the company’s profits by denying claims…….”

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Final Regs – Exemptions from Contraceptive Coverage Mandates

Monday, November 12th, 2018

Government continues to interfere in citizen’s sex lives……………………..

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Memorial Day 2018

Sunday, November 11th, 2018

 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 to Defend an ERISA Lawsuit

Sunday, November 11th, 2018

Firestone deference – Many ERISA plans use plan document language stipulating the plan administrator has the authority to interpret plan terms and resolve any ambiguities. The United States Supreme Court has held that when a plan contains this language, courts must show deference to the administrators and review their decisions under an arbitrary and capricious standard…………….

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Healthcare Waste is Costing Billions…………

Saturday, November 10th, 2018

………………and clients aren’t doing anything about it

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Sun Life Tops Market Expectations

Friday, November 9th, 2018

Business strategy is to focus on four pillars of growth: the Canadian home insurance and wealth market, US group benefits, global asset management, and distribution excellence in higher growth markets in Asia…………………………

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90+ Medications To Be Dropped by Insurance in 2019

Friday, November 9th, 2018

Drugs excluded includes brand-name drugs for which less expensive brand or generic alternatives are available in the market…………………………………..

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GR Data Insights: MSK – Quality matters………………

Thursday, November 8th, 2018

Grand Rounds is focused on reducing high cost claimants and improving patient outcomes and we have tangible evidence to prove it……………………

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Here Comes The Judge

Thursday, November 8th, 2018

 

 

He’ll give you time if you’re big or small
All in line for this court is neat
Peace brother, here comes the Judge 
Here comes the Judge…………………………………….

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Gridlock Sets In……………….

Thursday, November 8th, 2018

With a Democratic House, a Republican Senate, and President Trump in the White House, get ready for two years of maneuvering but little progress on health care…………..

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State of Utah Fights High Drug Prices With Results

Thursday, November 8th, 2018

The savings are anywhere between 38% to 75% well may save the state millions each year……..

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CMS Delays Dramatic Office-Visit Coding Changes Until 2021

Tuesday, November 6th, 2018

Proposed changes would have increased CPT 99213 by 30%……………..Primary Care Physicians lose out on pay raise. 

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Sunday, November 4th, 2018

How do you know if your surgeon is the best of the best or the worst of the worst? Unfortunately most patients play Russian Roulette when it comes to picking one………………….the results can be hazardous  to your health…………..

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More Texas Doctors Switch To Concierge Medicine Model

Sunday, November 4th, 2018

More doctors in Texas plan to make the switch to primary care out of frustration with the current healthcare system…………………………….

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Employers Are Becoming More Active in Healthcare Claims Management

Friday, November 2nd, 2018

“Employers are cutting out insurers completely and contracting directly with providers and/or creating near-site or on-site health clinics for primary care……………….More traditional cost management techniques are simply running out of gas. Employees, who have borne half of recent-year cost increases, simply can’t afford anymore,”

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San Patricio County Seeks Stop Loss Insurance

Friday, November 2nd, 2018

San Patricio County is seeking competitive specific stop loss proposals for a January 1, 2019 effective date. This 400 life case has been on Reference Based Pricing for the past ten years and does not access any managed care networks.

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Today’s Medical Students Lack Skills For Surgery

Wednesday, October 31st, 2018

New medical students have spent so much time on screens that they lack vital practical skills necessary to conduct life-saving operations, a leading surgeon has warned………………

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MedSave Management LLC

Wednesday, October 31st, 2018

MEDICAL BILL SOLUTIONS – A Medical Debt Resolution & Advocacy Services Company……

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Ballot Measure Limits Hospital Reimbursement To Cost +15%

Tuesday, October 30th, 2018

Voters in two California cities will decide two ballot measures that aim to curb healthcare costs, according to a Kaiser Health News report……………………

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Health Care Stole The American Dream – Here’s How We Take It Back

Tuesday, October 30th, 2018

RBP Quiz – What Level Of Benefits Will 100% of Medicare Buy?

Tuesday, October 30th, 2018

What level of benefits could one expect based on claim reimbursement of 100% of Medicare allowable charges? 

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Interview With Greg Everett, President of Payer Compass

Tuesday, October 30th, 2018

In this episode, The Phia Group chats once again with one of their Partners in Empowerment, Gregory S. Everett, President and CEO of Payer Compass.

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PBM Practices Exposed

Sunday, October 28th, 2018

PBMs use arbitrary and opaque DIR fees to derive record profits at the expense of independent pharmacies, plan sponsors and most importantly consumers……………………..

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How We Are Getting Screwed…………………

Sunday, October 28th, 2018

The healthcare industry is rife with secrets the healthcare industry doesn’t want you to know. If you have the courage to read this article, you may be wise to order The Schuessler Stick™, overnight delivery.

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70% of Americans Back Medicare For All?

Sunday, October 28th, 2018

Medicare for all is only one election away. Opponents may win 1,000 wars but proponents only need to win one. But this author writes “Medicare for All’ will never work, so let’s stop pushing it.”

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Hospital Gouging Practices Exposed

Sunday, October 28th, 2018

       Victor Lustig

Adam Conover explains hospital gouging practices 20 in this eye-opening 5-minute clip……..

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High Cost vs. High Quality: How Do You Navigate Health Insurance?

Sunday, October 28th, 2018

By Dave Chase

The most persistent myth in healthcare is that high cost equals high quality. It’s a proposition that holds across a great many products that are bought and sold in actual, functioning markets — but that’s not a description that applies to the U.S. healthcare industry.

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Texas Man Scams TriCare For More Than $50 Million

Sunday, October 28th, 2018

 

A Dallas man has admitted to defrauding a military health insurance program for $50 million.

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If You Can’t Beat Them, Join Them

Sunday, October 28th, 2018

Blue Cross of N. Carolina has announced a new, no network health plan (Reference Based Pricing). Coupled with a high deductible, BCBSNC touts a 33% premium savings.

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County Sues Insurance Broker Over Secret $250,000 Commission

Sunday, October 28th, 2018

The county’s complaint alleged broker accepted a $254,000 kickback for referring the county to a major insurer…………………in addition to fees paid directly by the county to the broker…………

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Trump Plans To Revamp Employer Based Health Care

Sunday, October 28th, 2018

The Beginning Of The End of Group Health Insurance?

The proposal would allow companies to use HRAs to reimburse employees’ premiums on the individual health-insurance market……………………….In lieu of adopting a group medical plan for employees, an employer can give employees money to purchase individual health insurance in the open market....

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Pharmacy Owner Charged In $10 Million Health Insurance Scam

Sunday, October 28th, 2018

An Alabama pharmacy owner has been charged as part of an alleged conspiracy to scam more than $10 million from a federal health insurance program………………

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If You Can’t Beat Them, Join Them

Friday, October 26th, 2018

Earlier this month we learned the state of North Carolina will be terminating their state health plan’s contract with Blue Cross and will instead adopt a Reference Based Pricing plan (Another State Adopts Reference Based Pricing Strategies). Now we learn Blue Cross of N. Carolina will be introducing a new, no network health plan, which is of course, Reference Based Pricing. Is this a case of “If you can’t beat them, join them?”

“It is normal comprehensive insurance, with a high deductible, and the main difference being that reimbursement is based on a ‘reference pricing’ approach similar to what state Treasurer (Dale) Folwell has recently proposed for the state employee plan…………….”

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HealthSmart

Friday, October 26th, 2018

Have you looked at HealthSmart lately? It’s an exciting time for us. We’ve had a busy year of growth, transition and powerful new solutions. Now more than ever, you should give us a look to see how we can help your clients and prospects. (more…)

Reference Based Pricing – Misconception #1

Thursday, October 25th, 2018

Every day you remain in an RBP plan, your risk of massive liability increases

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I Don’t Care

Monday, October 22nd, 2018

“Why aren’t you gonna pay for my prescription! My doctor ordered it!!!!”

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Balance Billing Is A Plan Sponsor’s Best Friend

Sunday, October 21st, 2018

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

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Uproar at Purdue

Thursday, October 18th, 2018

Employees upset with cost containment move by University officials………….“How long can we continue to offer health care coverage when we’re experiencing 20 percent to 30 percent increases on a regular basis?”

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KISS – Keep It Simple Surgery

Thursday, October 18th, 2018

The KISx Card was created as a solution for self-funded employers to tackle egregious surgical pricing while bringing simplicity to the employee experience……………….

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Blue Cross Blue Shield IL Sued for Fraud, Robbing Chicago Taxpayers

Wednesday, October 17th, 2018

Working The Spread is nothing new. Seems quite common. The article below is about a lawsuit in which spread pricing is alleged.

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Email Solicitation – To Good To Be True? You Decide

Wednesday, October 17th, 2018

We get unsolicited emails every day like the one below. This one touts a plan we have never heard of before, offering what appears to be “to good to be true” pricing. We thought we would share this for our three readers…………………….

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Paying for Coverage Without Any

Wednesday, October 17th, 2018

“What are you talking about! That’s insane” cried the HR lady. …….”I thought you needed to know” I replied.

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Chinese Government Demanding Big Discounts from Drugmakers

Monday, October 15th, 2018

The power of large numbers, 1.379 billion Chinese, brings big benefits when negotiating with drug manufacturers…………………………….

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Many Agents and Brokers Are Still Uncertain About “REFERENCE BASED PRICING”

Friday, October 12th, 2018

Breaking The Status Quo

Allied National employer groups are proving beyond the shadow of a doubt that the Freedom Plan (our reference based pricing reimbursement) is a better, lower cost, solution than traditional PPO networks.

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South Texas Health Cooperative

Friday, October 12th, 2018

Rest Easy In Our Pool

Taming Health Care Alligators Since 1998

The South Texas Health Cooperative (STHC) provides affordable health insurance to member school districts since 1998. Through careful risk management strategies, the STHC risk pool has achieved lower and stable costs while improving benefits at the same time.

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Wow! What a Difference!

Friday, October 12th, 2018
Earlier this year I moved a client from a BUCA PBM to an independent PBM. No benefit or formulary changes were made. Now that I have mature credible claim data on the move from the BUCA PBM to an independent PBM, I find Rx claims have reduced 30.1%.

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Big News! FTC to Probe Hospital Contracts

Thursday, October 11th, 2018

 

This may become the tipping point in health care reform. “The Senate Judiciary Committee chairman questions contract terms between insurers and hospital systems…………..contracts between insurers and hospital systems are limiting competition and pushing up health-care costs……………..”

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Gag Clauses Now Illegal

Thursday, October 11th, 2018

In an effort to increase drug price transparency, President Donald Trump signed two bills into law that ban insurers from writing gag clauses into their contracts with pharmacists………………

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Texas Spanks Humana – Who’s Gonna Pay For It?

Thursday, October 11th, 2018

Now let me get this straight. Humana tries and fails to negotiate a reasonable rate with enough in-network providers and is punished for it. Well, the solution is to get rid of the network and treat all providers as out-of-network. That’s what Reference Based Pricing plans do.……………..BTW guess where Humana is going to get the $700,000………………………..

– Bill Rusteberg

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Hospital Profits High In Indianapolis

Thursday, October 11th, 2018

Hospitals in central Indiana enjoy a higher profit margin than those elsewhere because they overcharge insurers…………………..

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UMMC / BCBS Squabble

Thursday, October 11th, 2018

The following article (Posted on Linkedin by Carl Schuessler) brings to mind deeper issues than the “surface” issues most consumers reading this will take away. The article hints of a gold mine of information leading to more questions than answers.

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We All Have Health Care Stockholm Syndrome

Monday, October 8th, 2018

“The Stockholm syndrome we have been suffering under is starting to break……………

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Another State Adopts Reference Based Pricing Strategies

Friday, October 5th, 2018

First it was Montana, a smallish state somewhere up north of us, who adopted Reference Based Pricing for their state health plan (Montana Adopts Reference Based Pricing Strategies). The little lady up north has big brass cojones! (Tough Negotiator Saves State Millions In Health Care).

Next there is California which is currently considering similar efforts. (California Assembly Bill 3087 Would Control Prices in the Commercial Market).

Now there is yet another state adopting Reference Based Pricing for their state employee plan. They must have heard about the little lady in Montana.

I thought Texas would lead the country on this. After all, several of us have been making noises in Austin over the past two years. Has Texas Lost It’s Cojones?.

– Bill Rusteberg

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Deductibles Hit $2,000 As Employers Intensify Cost Shift

Friday, October 5th, 2018

“Annual deductibles for Americans with employer-based health coverage are hurtling toward $2,000 on average, according to new studies analyzing employee medical benefits.”

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New England Journal of Medicine Slams Wellness Programs

Thursday, October 4th, 2018

“Outcomes-based wellness programs don’t work, so why do them?  There is no upside and therefore no argument in favor of poisoning the doctor-patient relationship. “

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Employer-Provided Health Insurance Approaches $20,000 a Year

Thursday, October 4th, 2018

Rising prices “chiefly tied to rising prices paid for health services.” Yet health care costs have remained essentially static for the past ten years. It’s the prices that have increased, not the cost of health care. – Bill Rusteberg

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San Antonio Emergency Room Raises Concerns

Thursday, October 4th, 2018
San Antonio’s newest Emergency Room service sparks interest among residents and government officials.  The Emergency Room “is not even open for business but is already causing controversy.”

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Tough Negotiator Saves State Millions In Health Care

Tuesday, October 2nd, 2018

 Marilyn Bartlett

Marilyn Bartlett took a deep breath, drew herself up to her full 5 feet and a smidge, and told the assembled handful of Montana officials that she had a radical strategy to bail out the state’s foundering benefit plan for its 30,000 employees and their families………………..

Will Texas be next?

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An Electrical Physical? How Much Is That?

Monday, October 1st, 2018

“No, I am not doing an electrical physical, I’m here for a cold and I don’t need that test!” ……“But sir, your Blue Cross will cover it” came her soothing reply.

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Who Are A Status Quo Health Insurance Salesman’s Two Best Friends?

Sunday, September 30th, 2018

If you are a status quo broker your two best friends are………………….

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Important Decision For Reference Based Pricing Lawsuit?

Saturday, September 29th, 2018

This is a suit where the hospital alleged numerous claims against the RBP vendor and the RBP vendor responded with a motion to dismiss………………………..
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Dr. Hodad

Friday, September 28th, 2018

Every medical community has a Dr. Hodad (Hands of Death & Destruction). Peers never talk about Dr. Hodad for fear of lawsuits…………………………………………..

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Generic Substitute for $94,000 Drug To Be Released Jan. 2019

Friday, September 28th, 2018

Harvoni drug cost in the US for a three month, 84 tablet course of therapy, is $94,500. The same drug if purchased in India for example costs $900 for 3 months 84 tablet course………………

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HealthSmart Reference Based Pricing Strategies

Thursday, September 27th, 2018

Our solution pays pre-negotiated rates to hospitals and facilities at various rates of Medicare pricing…..

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The End of The Health Insurance Carrier

Wednesday, September 26th, 2018

Health insurance carriers face slow but steady disintermediation by innovative next generation benefits advisers who are using alternative funding to take control of employer health plans and reduce costs………..the beginning of the end of these dinosaurs

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