Archive for the ‘Uncategorized’ Category

Transparency In Retirement Plans – Why Not Health Insurance Plans?

Thursday, June 28th, 2018

Employer thought they were paying their broker $126,000 per year. They were actually paying more than that………………………

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Status Quo Under Attack

Thursday, June 28th, 2018

Traditional health insurers, hospitals and independent physicians who refuse to change will become obsolete…………………………….

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Spreadsheet Fiasco Leads To Firing

Wednesday, June 27th, 2018

AUSTIN — The state has canceled five new managed-care contracts for low-income youngsters enrolled in the Children’s Health Insurance Program after finding errors in a spreadsheet used to evaluate bids.

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Texas County Believes in Magic

Wednesday, June 27th, 2018

A Texas county believes in magic. Facing ever increasing health care costs the county resorts to status quo strategies to temper increases – it’s called cost shifting……………………Meanwhile back at the ranch some Texas political subdivisions are improving benefits and lowering costs at the same time…………………………Health Care Strategies for Political Subdivisions

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Oklahoma Welcomes Medica

Wednesday, June 27th, 2018

Major Health Insurer Medica Brings New Competition to Individual and Family Health Insurance Market in Oklahoma…………………….

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Insurance Giant Acquires Wortham

Tuesday, June 26th, 2018

Wortham Insurance has agreed to a buyout by Marsh, a wholly owned subsidiary of New York-based Marsh & McLennan Companies Inc., combining two well-known names……………..

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Health Insurers Love The “Affordable Care Act”

Tuesday, June 26th, 2018

Health insurers are finding success in ObamaCare this year and are planning to expand their offerings in many states……………………..

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Is It Legal?

Monday, June 25th, 2018

Does anyone know for sure if the Texas Department of Insurance has any jurisdiction over Reference Based Pricing vendors who for a fee indemnify plan members against the risk of lawsuits and balance billing? Is the act of indemnification for a fee through transfer of risk the business of insurance?

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What Causes Hyperinflation in Medical Costs? It’s Health Insurance Stupid!

Monday, June 25th, 2018

Medical insurance directly causes price hyperinflation, because it insulates the patient from the financial impact of their medical care decisions…………………

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The Latest In Texas v. United States

Monday, June 25th, 2018

 

Following the Trump administration’s surprise move not to defend major components of the Affordable Care Act (ACA), much more attention is being paid to litigation over the individual mandate known as Texas v. United States.

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Amazon, Berkshire Hathaway, JP Morgan Target Point of Service Claim Adjudication

Monday, June 25th, 2018

POSCA is coming and it’s gonna be really cool……………………….

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Why Work For A Living When Stealing Is Easier?

Monday, June 25th, 2018

The city of Miami, Miami-Dade County public schools and several companies lost millions of dollars in health insurance payments as a result of being scammed by crooked clinics that submitted bogus claims for pain injections, according to newly filed indictments……………….

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The Impact of Catastrophic Claims  (Plan on Continuing Rate Increases)

Friday, June 22nd, 2018

 The Affordable Care Act did anything but make health care and health insurance more affordable.  The law that was supposed to drive costs down actually did the exact opposite……………………….

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BREAKING: Xerox Can’t Blame Doctors In $1B Texas Medicaid Fraud Row

Friday, June 22nd, 2018

Texas filed suit in May 2014 alleging the Xerox unit then known as ACS State Healthcare LLC, which administered claims for Texas from 2004 until 2012, signed off on $1.1 billion in claims for orthodontic services, a “substantial percentage” of which were allegedly paid in violation of Medicaid policies….…………….

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Government-Enabled Kickbacks Escalate Medical Prices

Friday, June 22nd, 2018

 

“Since the federal healthcare Anti-Kickback Statute GPO exception was created 30 years ago, the landscape has changed. The current GPO funding structure’s incentive is to ‘negotiate’ higher prices for its customers. The vendors with the most money can afford to pay the high fees and buy themselves into the game. The term ‘payola’—pay to play—comes to mind. The situation is exacerbated because insurers absorb the higher prices and thus hospitals may have less incentive to monitor pricing.”

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Must Reference Based Pricing Vendors Be Licensed?

Thursday, June 21st, 2018

Hospitals and their attorneys are getting creative. One issue of particular interest outlined in the article is apparently a new line of attack……………………..

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We’re not good golfers…………………

Thursday, June 21st, 2018

This is one of the best insurance agency websites I have seen in a long time. They memorialize their philosophy in a compelling manner………………………….

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Embodiment of Corruption: Your Health Insurance Network

Thursday, June 21st, 2018

Secret network pricing helps render patients defenseless against price gouging. It’s as absurd as grocers being permitted to keep the price of milk secret……………..

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Government Control of Health Care Loosened in Bold Move

Thursday, June 21st, 2018

Move keeps the government officials from using its power and influence to direct the practice of medicine……………………….

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Why Do Prescription Prices Vary By Up to 1,300%

Thursday, June 21st, 2018

Learn how a recent study found that prices for 5 commonly prescribed prescription drugs varied but up to 1,300% based on where the drugs were purchased.

Montana Experiences “Holy Cow” Moment

Thursday, June 21st, 2018

Montana’s high-stakes game of chicken designed to change how the state did business with its 60 hospitals, which accounted for 43 percent of employee health care costs, turning the normal purchasing process on its head……………………..

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Sana

Thursday, June 21st, 2018

Are you looking for new commission and bonus opportunities: Join us for a catered lunch at one of our local Texas events to learn how Sana is changing health insurance. Plus meet the founders.

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Reference-Based Pricing Litigation: Brick By Brick

Thursday, June 21st, 2018

By Scott Bennett – www.linkedin.com/in/scott-bennett-72014594/

Whether you believe modern Reference-Based Pricing models are presently being built, remodeled, or dismantled “brick by brick” truly depends on your perspective. Either way, this is an interesting time to review the recent challenges, results, and future risk created by this important approach to health care reimbursement, which has saved employers millions of dollars and sparked fierce conversations about reasonable value across the nation.

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Renting Medicare’s Provider Network

Wednesday, June 20th, 2018

 democratrepublican

An idea with bi-partisan support?

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Association Health Plans Go Into Effect

Wednesday, June 20th, 2018

This expansion of health care choices returns certain risk manager tools stolen by the government with the passage of the Affordable Care Act (ACA):

☐ Allows plans to exclude coverage for maternity care, prescription drugs, mental-health services and other ‘essential health benefits’ the ACA requires of coverage

☐ Plans will have more freedom to charge different prices depending on customers’ ages, genders and locations — something ACA coverage cannot do.

☐ The regulations erase a requirement that any association must already have existed for a purpose unrelated to health insurance.

☐ These plans will also be able to reduce administrative costs and strengthen negotiating power with providers from larger risk pools and greater economies of scale….

☐ Moves health-insurance regulation from the state level to the federal level.

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Peeling Back The Health Care Onion

Tuesday, June 19th, 2018

“Colorado hospitals statewide are paid an average of 290% of Medicare for inpatient services and 520% of Medicare for outpatient services…………………”

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Unwieldy Health Costs Often Stand Between Teachers And Fatter Paychecks

Tuesday, June 19th, 2018

In an era of $100,000-a-year drugs and government budget cuts, school districts are struggling to find the money to keep up their end of the bargain (providing benefits), forced to take away from classroom funding and even modest, cost-of-living raises. Many cash-strapped school boards, cities and legislatures view health care benefits as an unpredictable budget-buster.

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Don’t Hire An Actuary Because You May Get Really Bad News

Tuesday, June 19th, 2018

As a benefits consultant, if you not employing a licensed actuary providing these services your competition will……………………………..

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McAllen Independent School District Seeks Reference Based Pricing Vendor

Monday, June 18th, 2018
The McAllen Independent School District in deep South Texas is seeking competitive proposals for Reference Based Pricing plan administrator. Sources say the district is facing increasing health care costs and seeks to adopt a Reference Based Pricing plan option to offer in addition to their current PPO plan.

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Why You Will Never Win

Monday, June 18th, 2018

This was sent to several of us this afternoon from the one and only, Carl Schuessler, health care disruptor extraordinaire.

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Introductions Are Worth Big Bucks In The Insurance Industry

Thursday, June 14th, 2018

Earning commissions forever by simply making an introduction beats working for a living………….

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Owe Medical Bills? Don’t Pay Promptly, Pay Late & Join The 50% Club

Wednesday, June 13th, 2018

Members of the 50% Club subscribe to the Upside Down Economics of Health Care. They understand those who pay on time are screwing themselves and those that don’t are rewarded…………….

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Everyone Is Paying For Mary’s Deductible Because Mary Isn’t

Tuesday, June 12th, 2018

Lucky Mary is even more lucky now that her employer decided enough was enough…………………….

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Saving Rural Hospitals By Gaming The System?

Monday, June 11th, 2018

GAMING THE SYSTEM: Remote billing by rural hospitals is becoming a strategy to remain solvent? Medicare and commercial insurers tend to pay more for tests to sustain endangered rural hospitals compared with urban hospitals and especially outpatient labs………………………………

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Medicare For All & Reference Based Pricing

Monday, June 11th, 2018

Since Medicare For All is only a few elections away some employers are asking “Why wait? Let’s do it!

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Schools Buying Insurance Against Mass Shootings On The Rise

Sunday, June 10th, 2018

McGowan Cos., the largest underwriter of “active shooter” coverage, said they’re having a tough time keeping up with hundreds of inquiries from schools and other customers……………….

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PUNISHMENT LETTER 226-J

Saturday, June 9th, 2018

The government of the United States has sent out 30,000 punishment letters to employers who have failed to comply with the ever so popular AFFORDABLE HEALTH CARE ACT…………………………..

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Justice Dept. Says Crucial Provisions of Obamacare Are Unconstitutional

Friday, June 8th, 2018

Is it a tax if it raises no revenue………………………………….?

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Single Payer System Is One Election Away

Friday, June 8th, 2018

The Elephant In The Room is stirring, anxiously awaiting the fall mating season……………………….

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Accidents Of History Created U.S. Health System

Thursday, June 7th, 2018

How did Americans end up with a system in which employers pay for our health insurance? After all, they don’t pay for our groceries or our gas……………

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Welcome To The ATM World of Pharmacy

Thursday, June 7th, 2018

Pharmacist-supported self-service kiosk pharmacies ………………….

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Christian Healthcare Ministries – Alternative To Traditional Health Insurance

Thursday, June 7th, 2018

Christian Healthcare Ministries, one of several “health sharing ministries” whose members pool their resources to pay for one another’s health care expenses and has not had a rate increase in ten years……………………

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Co-Pay Tactic by Benefit Managers Credited with Cutting Prescription Drug Prices

Wednesday, June 6th, 2018

“It’s a constant cat and mouse game,” said Express Scripts Chief Medical Officer Steve Miller………………..

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Will California Criminalize PPOs?

Wednesday, June 6th, 2018

California would use Medicare rates as a floor for determining base amounts for providers and Medicare Advantage rates to set payments to health plans. Providers and health plans would be allowed to appeal for a higher amount based upon outstanding factors.

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Wellness Programs Don’t Work

Tuesday, June 5th, 2018

On its surface, who can argue with the concept of workplace wellness? How could there be anything wrong with corporations helping their employees reduce their risk of disease while saving money in the process?

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Renowned Texas Heart Transplant Program Suspends Operations

Tuesday, June 5th, 2018

Over 30% of patients who received heart transplants at St. Luke’s since the start of 2018 have died…………………………

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Drugmakers Blamed For Blocking Generics Have Jacked Up Prices And Cost U.S. Billions

Monday, June 4th, 2018

By Sydney Lupkin MAY 23, 2018

The Trump administration is shaming brand-name drug makers who refuse to sell samples so generics can be made from their products.

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Sex Sells – Winning Sales Quota by Banging Doctors?

Friday, June 1st, 2018

In 2012, Insys hired a new sales executive: Sunrise Lee, a Florida escort service manager and former strip club dancer with no academic degree, according to Guzman’s complaint. Burlakoff allegedly defended the decision, claiming, “Doctors really enjoyed spending time with her and found Sunrise to be a great listener.” He added, “She’s more of a closer.”

The regional sales manager reported that the new employee was “dumb as rocks, but that she was sleeping with another doctor and getting a lot of prescriptions out of him.” (more…)

The Hidden Monopolies That Raise Drug Prices

Thursday, May 31st, 2018

“PBMs don’t stop at legal money-making schemes……….. undisclosed rebates, artificial price inflations, kickbacks, steering, and other deceptive practices.”

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Why Did It Take So Long To Realize PPO’s Suck?

Thursday, May 31st, 2018

Agents, brokers and consultants, once so welded to the status quo, are now some of the most vocal and ardent supporters of the movement away from PPOs……………

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A Health Plan Veteran Is Tired of Provider Networks

Thursday, May 31st, 2018

“The health care game is rigged,…………………“That’s why we don’t play by their rules — and neither should you.”

Instead “Name your own price for health care services” (reference-based pricing strategy), along with rigorous auditing of facility claims.” 

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What is Trump Going To Do To PBM’s on Friday?

Wednesday, May 30th, 2018

President Trump Beating Up On PBMs In Oval Office?

“This system is completely broken … It is layered and layered with conflicts of interest. I don’t care who the PBM is.

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Risk Tolerance & Reference Based Pricing Strategies

Tuesday, May 29th, 2018

The problem I see with most health insurance consultants is almost all pre-determine a client’s tolerance for risk before determining where the risk tolerance actually lies.

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The Rising Cost of Cost Containment

Tuesday, May 29th, 2018

“Reference Based Reimbursement, while not perfect, provides a clear and distinct effort to bring attention to the actual cost of healthcare goods and services.” – Scott Haas

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Blue Cross Gets It Right

Tuesday, May 29th, 2018

If it’s not an emergency, Blue Cross Blue Shield won’t pay……………

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Economies of Scale In Health Care?

Tuesday, May 29th, 2018

In health care size make no difference……or does it?

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Memorial Day 2018

Friday, May 25th, 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. 

The battalion began the battle of Hatten with 33 officers and 748 en- listed men. Fifty-two hours later it had an effective strength of 11 officers and 253 enlisted men. All others were either killed, wounded or missing in action.

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Court Case Shows How Health Insurers Screw You

Thursday, May 24th, 2018

The insurer claimed—I’m not making this up—that its customers bore some of the financial responsibility for being ripped off because they weren’t paying close enough attention to what BCBSM was doing………………..

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Texas Ruling on $11,00 ER Bill May Have Long-Lasting Effects

Thursday, May 24th, 2018

The health care industry is closely watching a recent decision by the Texas Supreme Court that some say could have broader implications on how hospitals and health insurers negotiate their rates………………..

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New Resource For Texas Political Subdivisions

Wednesday, May 23rd, 2018

TAGCO RiskManagers, LLC (TAGCO) was formed by industry insiders as a resource for political subdivisions seeking solutions to rising healthcare costs…………………………

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Wednesday, May 23rd, 2018

We have the expertise, experience and bulldog tenacity to do the job and do it right……………………….

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Insurance For Pandemic Losses

Tuesday, May 22nd, 2018

Marsh has launched a new insurance product to provide financial protection to US-based businesses and their global operations affected by an infectious disease outbreak.

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The Phenomenon of Balance Billing Under PPACA

Tuesday, May 22nd, 2018

tomdick1

“Balance billing is representative of the last throes of a failed health care delivery system.”

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Games Brokers Play – A True Story

Tuesday, May 22nd, 2018

“Those who have data win. Those who have good data win a lot. Those who have real time data win all the time” – John W. Richards Jr, M.D.

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What Barbershops Can Teach About Delivering Health Care

Tuesday, May 22nd, 2018

Health care reimbursement in the United States usually focuses on the clinical encounter, at a physician office or hospital. This reflects a belief that care is best offered there, even when evidence says otherwise………………

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California Pushes To Give Illegals Full Health Care Benefits

Tuesday, May 22nd, 2018

“We are trying to address the fact that, whether you like it or not, our undocumented community needs the care, and we are paying for it anyway………………..California needs to be a laboratory for social change by taking the lead on progressive causes.”

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Anti-Assignment Clauses Are Enforceable

Monday, May 21st, 2018

The US Court of Appeals for the Third Circuit has held that anti-assignment clauses in health plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) generally are enforceable.

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Texas Healthcare Costs

Monday, May 21st, 2018

Article referred by David Wendel

The Texas Department of Insurance (TDI) has a new  website that provides cost information on more than 200 of the most common medical procedures, including many tests, surgeries and office visits.

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How Do You Measure Savings?

Saturday, May 19th, 2018

Question: How do we know we are doing better (saving money) this year than last year?

Answer: What was this year is last year plus or minus this year’s change.

Question: Then if change is the only constant why do we need to measure it? You don’t know if something is better if you didn’t know how to measure what it was before.

AUTHOR UNKNOWN

Slippery Slope Insurance Consulting?

Saturday, May 19th, 2018

By Molly Mulebriar

The City of New Braunfels RFP recently hired an insurance consultant to assist the city in a competitive RFP process for their employee health & welfare plan. Or did they hire two?

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Vermont To Permit Drug Imports From Canada

Saturday, May 19th, 2018

Vermont initiative creates a wholesale importation program to purchase high-cost drugs in Canada, where they often sell for less…………………Will retail Rx outlets then advertise and export these cheaper drugs from Vermont to the rest of the county? Could be a fantastic Rx mail-order business domiciled in Vermont…………….

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Turning Bronze Into Gold

Friday, May 18th, 2018

Turning Bronze Plans into Gold Plans at Bronze Plan costs is a common but unspoken strategy……………

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Physician Strikes It Rich in Health Care Arena

Thursday, May 17th, 2018

A Texas doctor used his million-dollar private jet or drove in his Maserati, which were both emblazoned with his initials “ZQ” between his offices in the Rio Grande Valley and San Antonio…………he purchased private jets, luxury vehicles, clothing from high-end retailers such as Louis Vuitton and exclusive real estate located throughout the United States and Mexico………..all garnered through his successful clinic operation in deep South Texas………………

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Medicare + Fee Schedules

Tuesday, May 15th, 2018

NATIONAL ASSOCIATION OF PREFERRED PROVIDERS (NAPP) Fee Schedule:

☑ Medicare plus 25% or 80% of billed charges, whichever is less.

THREE RIVERS PROVIDER NETWORK (TRPN) – PPO Fee Schedule:

125% of the existing Medical fee schedule as total reimbursement for covered services less applicable co-payments, co-insurance or deductibles.

IMAGINE A ONE  OR TWO PAGE HOSPITAL CONTRACT INCORPORATING THESE FEE SCHEDULES…………………….

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Refried Beans

Tuesday, May 15th, 2018

In a previous RFP for Section 125 Administration & Products, a bid was awarded in March 03-18-S40-229. Now we see the City of McAllen is re-bidding again. What happened?

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