http://m.lubbockonline.com/crime-and-courts/2012-04-23/healthsmarts-4-million-settlement-accepted-city-council

http://video.foxnews.com/v/1661612063001/hospitals-offering-cash-discounts-on-medical-bills

Sierra-Berkshire Associates, Inc., is a Reno based actuarial consulting firm for insurance carriers, Physician Hospital Organizations, Independent Practice Associations, Plan Sponsors, TPA’s and marketing organizations. One aspect of their work is designing group health insurance plans for insurance carriers.

In 2005, well before the market began to move away from managed care contracts,  Sierra-Berkshire  designed a program to approximate Medicare coverage features, employing an approach to medical expense treatment that already had wide acceptance by consumers and by the medical community. After all, most  hospitals and doctors accept Medicare patients  and almost never balance bill. So if a provider is happy to accept Medicare and the fees paid to them, they should be quite satisfied with the plan Sierra-Berkshire designed.

Attached is the Business Plan for the product developed by Sierra-Berkshire in 2005. Apparently the concept did not fly with the carrier/s and the product was never marketed.

ComparaMed Care

One of the principals of Sierra-Bershire writes: “We were too visionary in 2005 . . . no carriers were interested in our concept. Funny how stupid ideas become smart as wisdom is gained from the suffering of pain.”

Editor’s Note: The ComparaMed Care Plan would sell today, fully insured or self-funded. If almost all hospitals and doctors accept Medicare and don’t balance bill patients, why should they object to a Medicare Look-Alike Plan that provides the same exact benefits with the same exact reimbursement rates? “Hey doc, since you take Medicare patients, accept assignment of benefits, and dont balance bill,  you should have no problem with my insurance either.”

In a nutshell, a private insurance exchange is an online marketing tool. You may look up rates, but underwriting will ultimately determine what the real rates are going to be. Don’t get too excited about these exchanges – you already experienced  a similar version over the years, it’s called a spreadsheet. But, as you will see in the commentary below, some get quite excited about the ability to purchase insurance in the privacy of their homes without a pesky salesman breathing down their neck.

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It stared in the early 1990′s when a mid-west third party administrator started paying a client’s medical bills using Medicare as a pricing benchmark. Over time more clients did the same. Through trial and error this TPA became very good at paying claims using benchmarks instead of relying on managed care contracts that typically rely on negotiating charged based fees. (Negotiating charge based rates is the same as negotiating for a new automobile off the sticker price.)

Their clients have enjoyed significant savings and continue to do so.

Short term medical policies have traditionally been doing the same for years as have most dental plans.

Cost Plus  Insurance is gaining momentum with Group & Pension Administrators leading the charge. Since 2007, GPA has successfully managed their clients health care costs using this approach, saving 40% or more in real claim dollars, much to the displeasure of the last four remaining health carriers in the state. Over 100 Texas employers, to date, have adopted the Cost Plus model.

Competing TPA’s, taking note of GPA’s success,  are entering the market with variations/hybrids of the Cost Plus program.

It is apparent – getting away from managed care makes economic sense.

Editor’s Note: In-network charges are more than out-of-network charges? How can that be possible?

An implied contract is a contract agreed by non-verbal conduct, rather by explicit words. As defined by the United States Supreme Court, it is “an agreement ‘implied in fact’ as “founded upon the meeting of minds, which, although not embodied in an express contract, is inferred, as a fact, from conduct of the parties showing, in the light of the surrounding circumstances, their tacit understanding.”

Although the parties may not have exchanged words of agreement, their actions may indicate that an agreement existed anyway.

For example, when a patient goes to a doctor’s appointment, his actions indicate he intends to receive treatment in exchange for paying a reasonable/fair doctor’s fees. Likewise, by seeing the patient, the doctor’s actions indicate he intends to treat the patient in exchange for payment of the bill.

Editor’s Note: Almost no one ever pays a hospital’s full charge. Managed care contracts routinely pay much less than Charge Master rates. So does Medicare and Medicaid. Under an Implied In Fact Contract, the premise of consideration is based on fair and reasonable reimbursement. Thus is the foundation of Cost Plus Insurance (www.costplusinsurance.com )

  By Joe Paduda

Health plans, struggling to hold down costs, have finally given up, switching from U&C to a methodology based on Medicare’s RBRVS system, albeit one paying at 150% – 250% of Medicare – again for out of network care.

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In a study released Thursday, the Cambridge, Mass.-based WCRI said California’s medical costs per workers comp claim increased 8% per year from 2005 to 2009.

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What will life be like after ObamaCare is quashed by the Supreme Court? Will business as usual take hold with health insurance brokers resurrected from the dead and new carriers eagerly entering the market for quick and easy profits? Will government finally “back off” and let the market correct itself?

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