Archive for the ‘Uncategorized’ Category

How To Evaluate A PBM Offer

Tuesday, June 13th, 2017

Mildred Honeycomb, Famed PBM Professor at MMU

A two sentence tutorial on how to evaluate a PBM proposal…………………..

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Switch Operators Scheme to Undermine Plan’s Cost Savings Efforts

Tuesday, June 13th, 2017

Switch operators are like the Wizard of Oz: They’re hidden behind a curtain and being paid by manufacturers to end-run your cost-savings efforts. Therefore, you need to pull back the curtain, understand their machinations, and respond.

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Mulebriar Vents, Threatens Tahiti Move

Tuesday, June 13th, 2017

A large taxpayer supported employer now knows they are overpaying for health care……

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How An Industry Shifted From Protecting Patients To Seeking Profit

Sunday, June 11th, 2017

In 1993, before the Blues went for-profit, insurers spent 95 cents out of every dollar of premiums on medical care, which is called their “medical loss ratio.”

The average medical loss ratio is now closer to 80 percent. Some of the Blues were spending far less than that a decade into the new century.

The medical loss ratio at the Texas Blues, where the whole concept of health insurance started, was just 64.4 percent in 2010.

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Employers May Become Their Own PBM

Saturday, June 10th, 2017

Another form of direct contracting is when a plan sponsor outsources the administrative systems and support functions required to operate as a PBM, to a third-party vendor. These vendors can operate “behind the scene” and enable the plan sponsor to “private label” the PBM services.

The benefits to the plan sponsor includes marketplace branding, local control of utilization, formulary design control, acquisition-based drug costs and full share of rebates and manufacturers’ incentives. As a result of these comprehensive support services, plan sponsor’s of almost any size can potentially benefit from these new arrangements and may represent a significant improvement over traditional service contracts.

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Why GE, Boeing, Lowe’s, and Walmart Are Directly Buying Health Care for Employees

Friday, June 9th, 2017

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson

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Rosenthal’s Ten Commandments

Friday, June 9th, 2017

“In the past quarter century, the American medical system has stopped focusing on health or even science. Instead it attends more or less single-mindedly to its own profits.”

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Sprinklecare & Spitballs

Friday, June 9th, 2017

“So we spit-balled some ideas around and came up with this: The one package people are highly pleased with is Medicaid………………”

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Listserv Group Discusses Santa Claus & Single Payer System

Thursday, June 8th, 2017

Politicians act the way they do because Santa Claus is here and here to stay………..

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“ERISA Fiduciary Largest Undisclosed Risk I’ve Seen in My Career”

Thursday, June 8th, 2017

  David Chase

Emerging Litigation Could be the Savior to Our Dysfunctional Healthcare System. Here’s how………………..

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Former Pharma Reps School Docs on High Drug Costs

Thursday, June 8th, 2017

As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs — all to promote pills often costing thousands of dollars a year. Then he joined the Traitors Club of former pharma reps……….

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Telemedicine For Marijuana Lovers

Thursday, June 8th, 2017

HelloMD is a service that uses telemedicine to connect people with doctors willing and able to prescribe medical marijuana…………………

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Loaded Dice – PBM’s Are Winning The Cash & Rebate Game

Wednesday, June 7th, 2017

“Taken from a scene in the holiday classic, A Christmas Story, I double dog dare you now to ignore the new information I’m about to share with you” – Tyrone Squires

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Sun Life Reports +$1 Million Claimants Up 26%

Wednesday, June 7th, 2017

“The total of all Sun Life Stop-Loss claims reimbursements from 2013 to 2016 was $2.7 billion. If those stop-loss claims reimbursements are added to first-dollar catastrophic claims costs (the amount that employers pay before reaching the stop-loss deductible), the overall cost for catastrophic conditions was $6.1 billion…. Million-dollar+ claimants were up 26% compared to 2012-2015. In 2016, this group represented only 2.2% of claimants but accounted for 23% of all stop-loss claims reimbursements.”

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This Man Will Help You Get Out of Expensive Medical Bills

Wednesday, June 7th, 2017

I’m angry that people who don’t understand and can’t help themselves and don’t know how to fight back are getting ripped off every day.” – David Silverstein

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How To Reduce Health Care Costs & Improve Benefits At The Same Time

Wednesday, June 7th, 2017

davechasebook

We learned back in 2007 that we can reduce health care costs for our clients by 40-50% while improving benefits at the same time. Few listened then, afraid to break away from the status quo. Now we find articles like the following one by Dave Chase. This, and his upcoming book, is a Must Read for employer sponsored health plans – Bill Rusteberg

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Fiduciary Duties – You Mean that Stuff Applies to the Health Plan I Sponsor, Too?

Tuesday, June 6th, 2017

poyner

In the summer of 2016, over 100 of CIGNA’s self-insured health plan clients were sued with the complaint alleging breach of the defendants’ fiduciary duties under ERISA for engaging in widespread fraudulent behavior involving the use of plan funds. This case should serve as a wake-up call for employers sponsoring health plans nationwide – this will not be the last case of its kind to be filed.

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“Tax The Rich!” Liberals To Drive Aetna From State After 164 Years?

Sunday, June 4th, 2017

thatcherq

The Aetna insurance company has been based in Hartford, Conn., since 1853, but this week it said it is looking to move to another state…………

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San Benito ISD Believes Practice Makes Perfect

Sunday, June 4th, 2017

practiceNeed practice in responding to a Request for Proposal for Group Health Insurance? If so the San Benito Independent School District is here to help you……………..

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Express Scripts Lawsuit Reveals Dark Secrets

Saturday, June 3rd, 2017

cookie

No one has been able to determine how much a  PBM is profiting from its secret “deals” with manufacturers………..Express Scripts lawsuit raises eyebrows…………..

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BCBS Aggressively Tackles Non-Emergency ER Visits

Saturday, June 3rd, 2017

emergency

Blue Cross and Blue Shield of Georgia  has just informed its members that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their claim won’t be paid…………

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Texas Bill To Address Unconscionable ER Prices Fails To Pass

Saturday, June 3rd, 2017

shocked

TEXAS HOUSE BILL 3867 – AN ACT relating to unconscionable prices charged by certain health care facilities for medical care.

For purposes of Section 17.46(a), the term “false, misleading, or deceptive acts or practices” includes an emergency facility taking advantage of an individual’s medical condition by:

(1)  providing emergency care at an unconscionable price; or

(2)  demanding or charging an unconscionable price for or in connection with emergency care or other care at the facility.

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Half Of All U.S. Retail Jobs Could Vanish

Friday, June 2nd, 2017

checkout

“For the record, C-suite executives are actively engaged in reducing health care costs in the US, not by what they consider penny ante changes in plan design, but by replacing workers with robots and automation, self checkout machines, push button ordering in restaurants and drive thru food serves, etc etc etc. That not only cuts benefit costs but wages, workers comp, payroll taxes, sick leave, life insurance, training, on and on.  This is not to mention the rush to send US jobs to India and Mexico.  That’s how the c-suite is engaged.” – Tom Emerick  (www.emerickconsulting.com)

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Working The Spread

Thursday, June 1st, 2017

spread

Without disclosure to Plan Sponsor or the providers – the TPA simply misappropriated the difference between what Plaintiffs paid the TPA and what the TPA negotiated to pay the providers. Working the spread is a lucrative business………………..

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Your Fired!

Thursday, June 1st, 2017

fired

How the Molina Brothers Got Bounced From the Family Health-Care Firm…..

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$12,000,000 Man

Thursday, June 1st, 2017

yikes

“Everyone is trying to avoid the $12 million-man,. Because whoever catches him basically can’t make money.”

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The Leaks Keep Coming………..

Thursday, June 1st, 2017

leaks

“I want you to know that your long ordeal will soon be over,” Trump promised………….

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County Discovers $9.5 Million Health Plan Shortfall

Wednesday, May 31st, 2017

confused

Poor management leads to shortfall………………….

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Growing Profits From America’s Largest Health Insurers

Wednesday, May 31st, 2017

arrow

Why would a BUCA want to change the status quo? Doing business the same old way is in their best interests?

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Oncology Rx Treatments – Is An Extra Two Months of Life Worth $500,000?

Wednesday, May 31st, 2017

thumbdown

Based on a Cigna study, less than ½ of the oncology drugs approved from 2009-2014 have a known survival benefit…………..

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Prime Healthcare Acquires Mission Hospital

Wednesday, May 31st, 2017

prime1Prime Healthcare’s strategy is to take over struggling hospitals and cut out the least lucrative or money-losing services. Prime often cancels insurance contracts at its newly acquired hospitals, enabling it to charge the insurers higher rates for treating their members…..

See: http://www.latimes.com/business/hiltzik/la-fi-hiltzik-prime-feds-20160717-snap-story.html

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How Insurance Carriers Are Screwing Employer Sponsored Health Plans

Monday, May 29th, 2017

On behalf of the Free Market Medical Association (FMMA), thank you for joining me……

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Health Rosetta Benefits Advisor Certification

Monday, May 29th, 2017

rosetta

Show the market your commitment to putting client interests first……….

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Abel HR Services

Monday, May 29th, 2017

abel1Founded in 1992, Abel is a family-owned and operated Professional Employer Organization (HR Outsourcing Company) that provides small to mid-size firms with the advantages of “PEO Services”.

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Memorial Day 2017

Friday, May 26th, 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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Army Vet Hero of Manchester

Friday, May 26th, 2017

manchester

“I’m giving up my hospital bed on my ward for somebody who needs it…………….”

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Reference Based Webinar Invitation

Thursday, May 25th, 2017

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Moonbeam Leads Left Coast Towards Single Payer System

Thursday, May 25th, 2017

moonbeam2

Single payer system’s projected total health care costs is an estimated $50 billion to $100 billion a year. That’s a massive sum in a state where the entire general fund budget is $125 billion…………

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Fifth Circuit Holds That ERISA Preempts Provider’s Promissory Estoppel Claims

Tuesday, May 23rd, 2017

LIED

This case offers insight into how promissory estoppel may play a role where a provider seeks reimbursement from an ERISA plan.

Houston Metro alleges that before it provided medical services to any patient, it sought and “received verification by telephone from Defendants that each patient was covered by a health benefit plan,” and “that the particular procedures were covered by the health benefit plans and would be paid in accordance with the health benefit plan.”  Houston Metro alleges that it would not have provided the services if the defendants had not made these statements.

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“Your Day of Reckoning Is Fast Upon You”

Monday, May 22nd, 2017

mulebriar

An inner demon has been bothering me for the past 15 months….the demon screams to be released

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21 Things To Know About Balance Billing

Saturday, May 20th, 2017

smile

Reference Based Pricing Rocks!

The following article is entitled “20 Things To Know About Balance Billing.”

We added one more.

There is only one market strategy that protects consumers against balance billing – Reference Based Pricing (RBP) plans. Traditional managed care plans provide absolutely no protection against balance billing – consumers are on their own when they get one. Not so under RBP plans.

“In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.”

Consumer Union also reported 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn’t know their rights to fight the bills.

“So many times, people just give up [in surprise billing disputes],” Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR.

Which plan would you rather have? A traditional managed care plan with limited provider choice, ever increasing costs and balance billing liability. Or a Reference Based Pricing plan with lower cost, better benefits, unlimited choice of providers and balance billing protection? The choice has never been more clear………………..

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A.J. Lester & Associates

Friday, May 19th, 2017

ajl

Direct contracting isn’t for everyone. Employers who are satisfied with their insurance carrier’s excuses that blame increased health plan rates on rising medical costs may not be inter (more…)

Convicted Insurance Consultant Sentencing Postponed Again

Thursday, May 18th, 2017

haff111

Will Haff

The wheels of justice turn ever so slowly. Will Haff, a San Antonio insurance consultant and convicted felon now has a new August 9 date for sentencing.

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Refried Beans

Thursday, May 18th, 2017

refriedbeans

Why do Mexicans make refried beans? Because they didn’t make them right the first time. Same holds true for refried health care legislation………..

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What!……….I’m Going Back To Sleep!

Thursday, May 18th, 2017

ripvan

Waking up is hard to do. I’ve been trying for years. Even nightmares couldn’t wake me up until yesterday when I had a horrible one that lit me up like a Roman Candle. I shot out of my hiding place, raced to the library and found the 2017 Milliman Medical Index report. “Its true, its true, this is not another nightmarish dream, its true!” assured the sweet librarian.

“But it can’t be” I screamed. When I went to sleep in 1973 health insurance rates of $17 for individuals and $35 per month for family coverage were considered competitive! What the hell happened?”

“Government got involved, managed care contracts memorialized collaborative schemes to defraud consumers into thinking they were getting great “discounts” when in fact they were assured of paying more year after year, hospitals took lessons from used car salesman and invented something called a Charge Master, and health care supply chain managers (insurance brokers, agents and consultants) were tasked, and they accepted their role to make sure the new status quo remained forever” said the librarian with head hanging low and slumped shoulders.

“They say the only way to fix this is more government control through a single payer system. Go figure!” she continued. “I’m moving to Communist China where the free market in health care is alive and well!”

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Pittsburgh Teachers Thwart Healthcare Stealing From Education

Wednesday, May 17th, 2017

Branson

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson (Basic tenet of RiskManagers.us )

At long last, forward-looking school and union leaders recognize they share the same goals and are proving that it’s not that difficult to slay the healthcare cost beast even in an expensive and contentious healthcare market.” – David Chase

Editor’s Note: As Texas school districts struggle to maintain affordable health care for their employees, Pittsburgh and other school districts around the country are actually achieving health care cost reductions while improving benefits at the same same time. Instead of trying the same old strategies of the past, these districts are applying common sense solutions that work. Everyone wins; the consumer, medical providers and plan sponsors…………………….

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Attention Insurance Producers: Join Us And Earn Millions!

Tuesday, May 16th, 2017

omg This beats this! – BCBS To Pay $50,000 Broker Sales Incentive Each Fully Insured Group Sold

We have previously executed a similar strategy with a prescription benefit management company, Partners Rx (PRx), which we sold for $100,000,000 to Magellan Health in 2013.  That sale resulted in many producers receiving $1 million to over $4 million.  We anticipate that this opportunity will be even more lucrative.

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Tell Us Your Outrageous Health Care Stories

Tuesday, May 16th, 2017

 klepper

By Brian Klepper

Dave Chase, who has been our most eloquent teller of health care craziness stories in recent years, sent out a request the other day for alarming stories from the broker/consultant sector. He wrote:

Benefit brokers get paid more for doing a bad job (i.e., allowing healthcare costs to go up pays them more since they make a % of costs in many compensation schemes). They can get rewards for driving up spending such as trips or other undisclosed compensation. Tell us some of the most outrageous compensation schemes that help fuel hyperinflation in healthcare.

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UHC Pulls Plug On No-Charge Primary Care Plans

Tuesday, May 16th, 2017

actuary1111

A stunning failure of Relationship-Based Primary Care – Value-Based Benefit Plans?

UnitedHealth Group is shutting down its health plan experiment featuring staff providers offering unlimited primary and behavioral care at no charge………….Relationship-Based Primary Care – value-based benefit designs

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Patients Are Flocking To Urgent Care Clinics – Now Hospitals Are Too

Tuesday, May 16th, 2017

urgent12

The clinic business model is straightforward and attractive: Treat as many patients with minor injuries and illnesses as quickly as possible—usually in 30 minutes or less………..A typical immediate-care center sees 294 patients each week, a number Kalorama predicts will grow for the next four years. Per-site revenue is expected to increase to nearly $1.7 million by 2021……….

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Will State Employee Health Care Fix Hurt Texas Medical Schools?

Sunday, May 14th, 2017

medicalschool Medical School Students

Raise your hand. Which one of  you wants to treat Trooper Jones? He’s in the lounge with a cold………………..

Inserted in the nearly 900 page Senate budget bill are three paragraphs that would force the medical schools to treat members of the Employees Retirement System of Texas at a discounted rate.

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“ERISA Fiduciary Largest Undisclosed Risk I’ve Seen in My Career”

Friday, May 12th, 2017

davidchase 

Another Excellent Article By David Chase

Employer/union provided health benefits likely represent over two-thirds of industry profits as they wildly overpay for healthcare services due to the misperception that PPOs help save them money. In reality, PPO networks cost employers/unions dearly.

Increased outside scrutiny on how ERISA-regulated health plans spend their dollars could create immense potential liability for both company directors and health insurers across the country. 

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Implementing RBR “Done Right”…Begin with Diligence

Friday, May 12th, 2017

mcs

“It is my belief that any TPA or Advisor using this list of questions as a tool to evaluate options will be able to easily differentiate the pretenders, professional marketers and conscientious vendors offering a well-designed, well-supported offering.  Such differentiation is critical to the continued development of the RBR approach and disruption of traditional PPO use.” Glenn McLellan

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Dark Horse TRS ActiveCare Bill Gains Traction?

Friday, May 12th, 2017

 

trsactivecare

While we have been focusing on Senate Bill 789 we failed to notice the introduction of House Bill 1998 introduced back in February by the same representative who tried and failed to open the gates of freedom for school districts wanting out of TRS ActiveCare two years ago.

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Telemedicine Payment

Friday, May 12th, 2017

telephone123

In 2017 you CAN get paid for telehealth (non-face-to-face) services by both Medicare and Private Payers………….32 states now have laws requiring private payers to pay for telehealth services…………

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Spring Cleaning – Let’s Start With Supply Chain Managers

Thursday, May 11th, 2017

cleaningrefridge

By Bill Rusteberg

This is a preview of an upcoming blog posting that will address worst practices in the brokerage and TPA industry in this country. These practices are some of the best kept secrets rivaling the mystery of the Loch Ness Monster.

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David Contorno – Status Quo’s Worst Nightmare

Wednesday, May 10th, 2017

david111q

“Trusting carriers to manage your healthcare spend is like trusting American Express to manage your corporate expenses. We all know Amex gets a percentage of all charges, so if they had their way, employees would charge anything and everything on it. After all, the employer pays the bill. Wait, same with health insurance. They make a vig (the interest on a shark’s loan) on every claim and the employer pays the bill…..” – David Contorno

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High Performance Health Care – Facts & Ideas

Wednesday, May 10th, 2017

Yesterday, as I was keynoting the final day of the Health & Benefits Leadership Conference in Las Vegas, the conference had an artist from Maestro Health drawing what she heard in real time. The fun and interesting result is below. A particularly nice touch to the conference.

07_High_Performance_Healthcare_InkFactory_Large

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Patients Go Public With Bills, Hospitals Respond

Tuesday, May 9th, 2017

angryman

As patients take hospital bill issues public, hospitals take stock of their practice……

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LevelFunded Health

Monday, May 8th, 2017

levelfundedh

LevelFunded Health is a national, direct to employer distribution platform focused on level and self-insured benefit programs for small to mid-size employer groups. For businesses with employees ranging from 50 to 1,000; it can help to immediately save these businesses anywhere from $50,000 to $2 million per year on healthcare costs, while simultaneously improving benefits.

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Austin Chapter of the Free Market Medical Association May Meeting

Monday, May 8th, 2017

freemarketmedical

Join the Austin Chapter of the Free Market Medical Association for our May Meeting on Wednesday,May 10th at 11:30a-1:00p at Independent Bankers Assoc of Texas 1700 Rio Grande St, Third Floor Third Floor – Doyle Conference Room Austin 78701.

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South Texas Physician Becomes TMA President

Monday, May 8th, 2017

cardenas

He helped lead TMA’s fight for medical liability reform, which became Texas law in 2003.

“When you get shot at all the time, when 70 percent or more of your colleagues are named in a lawsuit or a party to a lawsuit and you can no longer recruit, retain or attract [physicians] to your community to do what needed to be done for the health of your community, something had to change,” Cardenas said. “That was something that drove me and others in our community to stand up and say, ‘No more.’ We came together and organized.” – Carlos J. Cardenas, M.D.

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GOP’s Bill Is Still Government-Run Health Care

Monday, May 8th, 2017

bride

Remember in 1966 when Medicare was passed into law? Republicans stood by their principles and were united against this move to “socialized medicine.” They fought hard to stop the measure. Now you can’t find one Republican against Medicare. One’s principles go by the wayside with the absence of term limits. The same will hold true in America’s irreversible move to a single payer system.

“The only difference between Republicans and Democrats is Republicans take just a little bit longer to get there” – Bill Rusteberg

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UHC “Overpayment” Offset Practice Dealt Deathblow

Monday, May 8th, 2017

flores Mark Flores

Several internal United documents emphasize this point and gush about how cross-plan offsetting will allow United to take money for itself out of the pockets of the self-insured plans…”

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Texas Clarifies Status of Texas Captives

Sunday, May 7th, 2017

captives

With these clarifications, it is now clear that Texas captives can play a significant role in employee benefit plans for health benefits……………

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Association Health Plans

Sunday, May 7th, 2017

novel

The rising cost of health insurance remains a major problem for small business owners. In 2015, 25 percent fewer small businesses offered health insurance than when the Affordable Care Act (ACA) passed in 2010, a significant drop in small business coverage.

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A New Blog for Employer and Union Benefits Managers and Their Advisors

Saturday, May 6th, 2017

klepper Brian Klepper

Reading yet another excellent post on an important topic – PPOs in this case, see below – by South Texas broker Bill Rusteberg  the other day, I was struck that there are few go-to sites dedicated to the very significant challenges faced by health benefits managers, consultants and other health benefits professionals…………………

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Plan Sponsors Beware – Lawyers Preparing Lawsuits

Saturday, May 6th, 2017

sued

Employers who fail to prudently manage health plan assets creates a lucrative opportunity for plaintiff’s attorneys………Significant liability for companies and plan trustees…………..

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An Electrical Physical? How Much Is That?

Friday, May 5th, 2017

dayandnightclinic

“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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Deep Throat & Cheap Vasectomies in New Orleans

Friday, May 5th, 2017

deepWe have more wannabe Deep Throats than we can count. We have providers calling to trash their competitors — some anonymously, some not. We have been a topic of jokes at a school fundraiser where one of the auction gifts was a … vasectomy, cheap!

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70 Year Old Snow Flake Masks Love For Trump

Friday, May 5th, 2017

loveIn an effort to mask her deep love and affection for President Trump, famous tabloid figure calls The Donald the “mad King George III.”

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List of Obamacare Taxes Repealed

Friday, May 5th, 2017

obamasmile

The American Health Care Act (HR 1628) passed by the House today reduces taxes on the American people by over $1 trillion. The bill abolishes the following taxes imposed by Obama and the Democrat party in 2010 as part of Obamacare:

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Direct Descendant of Nostradamus Predicts Single Payer System Imminent

Friday, May 5th, 2017

believeitornot

“In less than seven years, we’ll be in a single-payer system.”

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Weslaco ISD Hires New Insurance Consultant

Thursday, May 4th, 2017

recordbreakerFor the past eight years Valley Risk Management has provided valuable risk management oversight for the district. An eight year tenure with a South Texas school district has to be one for the record books …………………

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HB 3976 Passes Out Of Texas House

Thursday, May 4th, 2017

surpriseHouse Bill 3976 passed out of the Texas House in a 143-0 vote this afternoon (May 3). The bill relates to making dramatic changes to TRS-Care, including providing $633 million towards continuing the state-run retiree health insurance program.
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