Molly Mulebriar Org. looking for assistance on single case project – http://mollymulebriar.org/report/

In the insurance brokerage business, an introduction can be worth thousands, and even millions of dollars, costing the recipient the same amount.

“Let me put you in touch with ABC Insurance Company. They have a great product you can use in your brokerage. I already told them that you would be calling” chortled John Brown, local insurance guru in Buffalo Breath, Montana.

What happened is John has “covered his base” by cutting a deal with ABC Insurance Company prior to making the introduction. “Hey Bruce, this is John. I’ve got an insurance agent down in Little Rabbit, Arkansas that I can send your way. Has a big case that I think he can place with you. I need a cut of the commission, ok?”

“Sure John, we will put him under you in our system and for the rest of his life, on all sales he makes with us, you will get a cut of the commissions. He will never know what you are making. What is his name so I can log him in?”"

“Great, but what if this guy tries to go around me and cut me out?”

“No problem, we will protect you.”

John now has an annuity. From that point on, on every sale his referral generates, John will be paid. Life is good.

Editor’s Note: If you need a PBM that offers a completely transparent, pass-through contract, that will save your client big bucks guaranteed, contact us during regular business hours.

A federal judge has denied a request from Blue Cross Blue Shield of Michigan to dismiss a suit filed by federal and state governments, alleging the payor’s use of certain hospital contracts stifles competition, according to a Detroit News report.

In a court hearing, U.S. District Judge Denise Page Hood said she would produce a written order denying BCBS’ request, allowing the lawsuit by the U.S. Justice Department and former Michigan Attorney General Mike Cox to proceed. Judge Hood said she is still “tweaking” the order, according to the report.

The state and U.S. government claim BCBS contracts with more than half of Michigan’s hospitals prevent them from charging other insurance companies lower prices. The governments also argue that, in some cases, BCBS agreed to boost reimbursements to hospitals if they charged competing insurance companies higher rates.

BCBS argued to dismiss the case, citing its use of the “most favored nation” clause has already been approved by the state insurance commissioner and the contract conditions help keep costs down for beneficiaries.

Read the Detroit News report on BCBS Michigan and its pending lawsuit.

                                 Hidalgo County is seeking bids for insurance consultant to assist the county in evaluating their self-funded health insurance program -  http://www.co.hidalgo.tx.us/bids.aspx?bidID=348

                  The Brownsville Independent School District, the largest employer south of San Antonio with over 7,000 employees, has decided to switch administration of their self-funded health plan from Mutual Assurance Administrators to Blue Cross & Blue Shield of Texas.

We are not surprised – http://blog.riskmanagers.us/?p=6216

There has been some controversy regarding purported PPO discounts through the BISD program for several years. Currently the BISD is in a lawsuit against the HealthSmart PPO network for alledged failure to deliver promised “savings” to the BISD health plan.

A switch from HealthSmart to the Texas True Choice PPO network was purported to have saved the district over $9,000,000 in provider discounts, however that has now come under some scrutiny. Costs under the TTC plan have gone up, not down, with projections to top over $55 million for the year.

The current BISD insurance consultant says that BCBS of Texas has superior discounts and will save the district millions of dollars. During a school board meeting it was represented that projected costs to the district under BCBS of Texas for the upcoming year will be approximately $45 million, or about $10 million less than what was assumed to be the cost should the district had continued with the TTC plan.

Using logic based on representations made by various sources through mainstream media and supported by local blogs, if the cost reduced $9 million going from HealthSmart to Texas True Choice, but now the cost is expected to drop $10 million going from Texas True Choice to Blue Cross, the  logical conclusion  is that the Blue Cross discounts are about $20 million less than what HealthSmart’s were. If the HealthSmart annual cost in it’s last year at BISD was about $42 million as has been represented from some quarters, then under BCBS the annual spend should drop to around $22 million in total.  ($9 million TTC savings plus $10 million  BCBS savings = $19 million savings applied to HealthSmart cost of $42 million = net annual cost to BISD of $23 million). A $23 million spend represents more than a 50% reduction in costs going from HealthSmart to Texas True Choice to Blue Cross.  THEREFORE, BLUE CROSS MUST HAVE PPO DISCOUNTS THAT ARE 50% OR MORE BETTER THAN HEALTHSMART PPO DISCOUNTS.

A group the size of the BISD is 100% credible.

But wait a minute! If projected costs for the next plan year under Blue Cross is $45 million, where is the missing $22 million in savings? The costs under Blue Cross should be only $23 million, not $ 45 million! Somewhere, somehow there is $22 million missing. Maybe it’s over at the Brownsville Navigation District.

Of course, logic can be twisted to one’s own persuasion and point-of-view. We hope that the exercise in logic demonstated above will cause some pause in the reader’s mind and strike a chord deep within to sustain a burning drive to learn the truth about PPO discounts.

The current BISD insurance consultant is the same consulting firm that recommended HealthSmart PPO several years ago.

The BISD approved continuing with ING as the stop loss carrier. In Plan Year 2009 -2010the commissions on the ING stop loss policy increased 50% as recommended by the insurance consultant on hire at that time – Stop Loss Contract

Additonal reading: http://blog.riskmanagers.us/?p=3790 - http://carebrownsville.blogspot.com/2011/01/you-want-specifics-mr-springston-how.html

 Editor’s Note: Selling group health insurance these days has become centered around who has the best and lowest provider pricing. But how do you determine who has the best pricing? Blue Cross will tell you they have the best, so will Aetna, Humana, Cigna and others such as HealthSmart and Texas True Choice. Yet the payer (consumer) cannot see any PPO contracts (proprietary, cant tell you or would have to kill you), and more importantly neither or any of the above mentioned providers have access to their competitior’s contracts either. So, a logical conclusion is “Everybody must be Lying About PPO Discounts. “   But, we know the truth, don’t we Don Pedro?

Molly Mulebriar informs us that her investigative team on assignment in South Texas will  post a Special Report soon at www.MollyMulebriar.org .  We have no idea the content of the report but look forward to reviewing it. Mulebriar does good work, especially in the area of insurance fraud.

For you dentists in Texas who generously perform intricate fillings, extractions and root canals on squirmy kids for near-charity Medicaid fees and far too much hassle, I sincerely thank you for your kind hearts.

However, it’s only fair that Medicaid providers in Texas be warned about developments revealed in WFAA’s breaking report, “Feds investigate Texas dental Medicaid program” by Byron Harris.

http://www.wfaa.com/news/investigates/Feds-Investigate-Texas-Dental-Medicaid-Program–128414743.html

“In a letter to the state, the inspector general [US Dept. of HHS] says it will examine the ‘authorization process for orthodontic treatment’ under Texas Medicaid.” Harris adds, “Texas spent $184 million on Medicaid orthodontics last year; that’s nine times as much as California, which spent $19.5 million.”

Sure. We learned that Texas orthodontists have much better lobbyists than California’s, but one shouldn’t miss the subtle warning to dentists about doing business with Texas that is hidden deeper in the article. Billy Millwee of the Texas Health and Human Services Commission said “if taxpayers money had been lost, the attorney general might take action to get it back.”

Doc, imagine years from now, receiving a letter from the Attorney General demanding a refund of hard-earned money you had to fight the state for to begin with. If Texans trust the future of Medicaid to the whims of unaccountable state and federal bureaucrats who don’t know how to conduct business, even more of the poor will be driven to already over-burdened charity clinics. Let’s not play these games. People depend on us.

It’s clear that orthodontists in Texas were ambitious, and their opportunism was wrong. But a deal’s a deal, Texas. Move on. The amount of money state leaders carelessly squandered is not worth the years of harm refund demands from the AG would cause the poor in Texas.

Who would want to do business with the state under that threat?

D. Kellus Pruitt DDS – darrellpk@tx.rr.com

Editor’s Note: Dr. Pruitt is a Ft. Worth dentist

A Valdosta-based company told state lawmakers Monday that hospitals are unjustifiably harassing its employees over medical bills. The problem involves balance billing, a practice whereby a medical provider sends a patient a bill for charges beyond what is paid by a health plan.

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        WASHINGTON (Reuters) – The price of Seattle Genetics Inc’s blood cancer drug Adcetris could top $100,000 for a course of treatment, becoming the latest cancer medicine to come at a high cost.

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