“Financial woes afflicting the TRS-ActiveCare health insurance plan for school employees could lead to TRS staff recommending that the system’s board adopt unprecedented midyear premium hikes.”
Archive for December, 2013
Protected: Medical Providers, Patients, Health Networks To Benefit From Innovative Insurance ProductTuesday, December 31st, 2013
UFO Abduction Insurance Now Available – New Opportunity For Health Insurance Agents Facing Extinction?Monday, December 30th, 2013
“Have I ever been abducted by aliens in the past, and if so, did they install a tracking device about or within my person?…..Do I enjoy taking long walks alone in the woods at night?….Do I have plans to venture outside of the earth’s atmosphere for either business or pleasure within the next decade?……Have I ever worn a headpiece made of tinfoil?”
Another notice we received today from our many sources in our attempt to keep up with ObamaCare and the continuous changes that come every day. Easy reading – enjoy!:
“On page 65095, in the Federal Register of October 30, 2013, we added subpart M ‘Oversight and Program Integrity Standards for State Exchanges’ to the regulations text at 45 CFR part 155. While it was clear from the preamble and regulations text that subpart M applies to all Exchanges, including small business health options program (SHOP) Exchanges, due to an oversight we inadvertently omitted cross-referencing new subpart M at section 155.705(a) of the regulations in part 155, subpart H-Exchange Functions: Small Business Health Options Program. Accordingly, we are revising section 155.705(a) so that the regulations in part 155 consistently reflect our policy that all Exchanges, including SHOP Exchanges, must carry out the required functions of an Exchange that are set forth at subpart M.” (U.S. Department of Health and Human Services)
Editor’s Note: Here is a translation in layman’s terms:
“Rather than embracing a single-payer system, the United States is more likely to stumble, in fits and starts, toward something resembling officially sanctioned tiering of the American health care experience by income class…” Uwe Reinhardt
“Imagine going to a physician’s office and finding two waiting rooms. Since you are wealthy (even after taxes) and have “real” insurance, you are directed to the waiting room on the right. Comfortable lounge chairs, coffee bar and large full screen movie playing in the far end while computer stations on the other end for your personal use while waiting for the doctor. But alas, you won’t have much time to surf the net since waiting times in the room on the right averages 10 minutes or less.
Those other, less fortunate and lower income patients with government insurance are directed to the waiting room on the left. Wooden church pews are loaded with sad eyed mothers with squalling children. It’s cheaper to take the children to the doctor than hiring a babysitter, so the whole family is there to provide moral support to little Johnny and his runny nose. They know the drill…….out comes their sack lunches since the waiting times can be two, three or four hours before they get to see Sarah, their favorite nurse practicioner…..” William Rusteberg
The health benefits community has been waiting for some force — a shift in employer preferences, a shift in insurer strategies, an upheaval in Washington or state capitals — to drop a hammer and smash everything to bits for decades.
People have been watching for the hammer ever since managed care organizations came along and smashed Indemnity Plan World.
Preferred provider organizations came along and loosened the grip of the health maintenance organizations, and health savings accounts came along and slowly revived the concept of imposing a meaningful deductible. But Managed Care World puttered along, never really changing in any dramatic way.
A recent post on another website regarding Medicare benchmark pricing (in lieu of a PPO), raises questions as to the legality of certain third party intermediaries representing patients vis-à-vis the provider under Cost Plus, Reference Based Pricing and other similar schemes which are gaining traction (and the attention of hospitals) in the market.
“It seems Nancy Pelosi was wrong when she said “we have to pass” ObamaCare to “find out what’s in it.” No one may ever know because the White House keeps treating the Affordable Care Act’s text as a mere suggestion subject to day-to-day revision. Its latest political retrofit is the most brazen: President Obama is partly suspending the individual mandate….The only political explanation for relaxing enforcement of the individual mandate—even at the risk of destabilizing ObamaCare in the long term—is that the White House is panicked that the whole entitlement is endangered.”
“The recognition of concierge medicine in the law has spurred a few insurance companies, including Cigna Corp., to build new employee health plans around the model….fueling the trend is a little-known clause tucked into the health-care law that allows direct primary-care to count as ACA-compliant insurance, as long as it is bundled with a “wraparound” catastrophic medical policy to cover emergencies.”
Editor’s Note: This niche market is ripe for the picking. Aligning stop loss cover with catastrophic wrap-around coverage, in conjunction with concierge medicine is easy to build for those clients ready for innovative, cost effective, and now “legal” employee benefit offerings. The Western Frontier has never looked as attractive than it does today………
Optimism and Innovation in Health Care Battered by Reality – By Robert Cloutier
Editor’s Note: Robert Cloutier is a fellow HealthCare Revolutionary and a friend of ours. His personal story of bringing transparency and sanity to the health care delivery system is stunning. Success of a product and service to the market depends on competition. To be competitive means not only having a pricing structure that consumers embrace, but quality of goods and services are equally important. No so in our current health care delivery system.
For some employers, the PPACA brought with it a new motivation to self-insure the health coverage of their employees. Recently however, there have been hints that new legislation may be passed which will eliminate stop-loss insurance and therefore threaten the ability of many employers to self-insure.
To counter this, legislation has been proposed in the Senate protecting the right of employers to fund their health benefits. Titled the “The Self Insurance Protection Act”, this proposed legislation protects the right of employers to continue to offer self-funded insurance plans and pay employee healthcare costs directly.
“……a battle is brewing in at least a half dozen states that are challenging limited choice of doctors and hospitals in public exchange options…..”
“Well I don’t know why I came here tonight, I got the feeling that something ain’t right,” the song hummed through the speakers of the DC medical examiner’s office. Something definitely is not right, I thought as I watched the pathologist and his assistant begin the first autopsy of the morning. With rough strokes, the assistant dissembled the body before us.”
“This blog is one of the very few places on the Internet ― maybe the only place ― where you can find out about these perverse incentives and the reasons why they arise” – John Goodman
“Suppose an employee pays 25% of the premium after tax. Given a 40% marginal tax rate (combined federal and state income taxes and payroll taxes), the insurance would have been 10% cheaper if the employer had made the full payment instead. If the employee pays 50% of the premium, a 20% discount is left on the table…..”
“In saying this I am ignoring the fact that most employers mis-price the employee’s share of the premium. Although small employers may age rate, large employers typically charge employees the same premium regardless of age. If employees are charged 25% of the premium, this means that a young worker’s share is closer to 50% of the real cost and an older worker’s share is closer to 10%. ……..”
“Almost all the insurance products being sold to employers these days have first dollar coverage (or small co-payments) for doctor visits and preventive care……. At the same time, these plans can cost an employee $10,000 or more in case of a hospital visit. (The new law restricts the total.)”
“INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.”
That is the warning at the bottom of every page of the 217-page confidential Obamacare Navigator training manual – http://www.healthreformgps.org/wp-content/uploads/navigator-SOP-manual-8-26.pdf
“Pharmaceutical companies know this. If they only raise the price of a few medications briefly it probably won’t be noticed. They also know that they can make a lot of money for a short time each time they do this. Nasty, but in the medical “market,” it works.”
Two competing TPA’s are quoting Cost Plus / Reference Based Pricing / Medicare Plus for ABC Fence Company in Brownsville, Texas. How does one evaluate these offers to determine best value?
HealthSmart Holdings, Inc. announced today that it has entered into a definitive agreement to acquire Benefit Management Systems, Inc. and its affiliate Diversified Benefit Consultants, Inc. (collectively, BMS). Terms of the transaction were not disclosed.
If you work with employer groups who need administrative support to help provide quality GROUP Retiree Medical and Rx benefits to better support retiree commitments, but are stretched thin in the HR Department, call us. We help employers get out of the benefits business and manage all phases of providing a quality Retiree Medical and Rx programs to Retirees and their Spouses, including policy issue, billing, claims payment and customer service. Many employers are ready to get out of the insurance business. CALL US TODAY… WE CAN ESTABLISH RETIREE MEDICAL PROGRAMS ANY MONTH OF THE YEAR.
Thomas M. Geib, (800) 866-8056 – Toll Free www.tagcomet.com
The Wall Street Journal cited some of our research in their recent article “High Deductibles Fuel New Worries of Health-Law Sticker Shock.” The larger study from which the data was derived was released this morning. For each metal plan (i.e. bronze, silver, gold, and platinum), the study examined the average cost for:
- Individual and family deductibles
- Primary care visit charges
- Specialist charges
- Individual and family maximum out-of-pocket costs per year
One of the surprising findings was that the average deducible amount found for each metal plan did not progress downward across metal plans evenly. This finding was surprising because the actuarial value differences among the plans are consistently 10% more medical costs covered for each higher level of metal plan. For example, the bronze health plan covers 60% of medical costs for a typical enrollee population and the average deductible for a bronze plan across 34 state exchanges was $5,081. The platinum health plan, in contrast, covers 90% of medical costs for a typical enrollee population but had an average deductible of only $347.
Assuming that actuarial certifications for all plans were correct, why would bronze plans that cover one third less medical costs than a platinum plan have an average deductible that was nearly 15 times higher than the average deductible for the platinum plan? The short answer is because the two plan categories are distributing cost-sharing in different areas. However, this answer does not explain the heavy reliance on deductible for cost-sharing among bronze plans.
The findings our of our study help illuminate why it is so important for consumers to include their anticipated healthcare use within health plan comparisons. Shopping by premium alone could result in higher annual costs for healthcare if a person has moderate use of healthcare services.
The full research can be reviewed in our InfoStat “Deductibles, Out-Of-Pocket Costs, and the Affordable Care Act.”
By Kevin Coleman
Cost of care decreased and patient satisfaction jumped in a remote monitoring pilot project conducted by CHRISTUS St. Michael Health System in Texarkana, Texas, according to research presented this week at the mHealth Summit in Washington, D.C.
Much has been made about the promise of “if you like your current plan you can keep it.” But what if I like my Obamacare plan that I get in 2014? Will I be able to keep that? The simple answer is – No.
Caprock Health Group Acquires Third Party Administration division of Employee Benefit Services
Lubbock, TX/San Antonio, TX – December 12, 2013 – Caprock Health Group announced today that it has completed the acquisition of the third party administration division of Employee Benefit Services (EBS). EBS is an established healthcare services company providing brokerage services, benefits administration, eligibility management and third party administration services. The EBS third party administration (TPA) division serves self-funded employer health plans in the greater San Antonio, Texas Region. The acquisition makes Caprock Health Group one of the largest health care services organizations in the region.
The acquisition will continue Caprock Health Group’s strategic initiative related to geographic expansion, product diversification and growth. The merger of Caprock and EBS’s TPA will enhance the Caprock Health Group’s position as an industry leader in innovative plan management and cost containment services.
“The Villemain family have done a tremendous job developing a high quality, service oriented Third Party Administrative firm. Caprock Health Group is proud to have been chosen to advance the EBS service model through our acquisition of EBS. EBS is a great complement to the Caprock Health Group of family companies. Their business model is a very good fit and they have great leadership who know our industry and will continue to support the self-funded employer groups involved,” said David Adams, CEO of Caprock Health Group.
“Employee Benefit Services is pleased with the completion of the transition of our TPA Division to Caprock Health Group. We feel this acquisition of our TPA division will be beneficial for our clients, and at the same time, better align EBS’s services for long term growth,” said EBS President Pete Villemain.
Employee Benefit Services is a full service Brokerage Firm. Family owned and operated for 25 years the Villemain family offers clients quality products and services delivered promptly at competitive prices. As a brokerage EBS works directly with clients to offer a full line of benefit products and services as well as consulting with employers on customized self- insured employee benefit programs. Through a mutually beneficial partnership, they promote a spirit of teamwork among clients, employees and vendors.
Caprock Health Group is a health care services organization comprised of affiliated companies working in close coordination to provide an effective integrated solution for employers and insurance brokers who want the very best in self-funded health plan management and fully insured plan access. Caprock Health Group offers a full suite of products which are designed to provide each employer maximum cost savings. Our focus is helping employers manage long-term health care costs by empowering employees through education, creating healthier consumers, and incorporating highly effective cost containment strategies.
Annette Alonzo, Director of Marketing, Caprock Health Group
Editor’s Note: With the recent acquisition of Verity National (http://blog.riskmanagers.us/?p=12168) and now EBS, Caprock is well positioned to become the premier TPA for the San Antonio area. Caprock provides competitive Cost Plus, Reference Based and Medicare Plus pricing models ( http://blog.riskmanagers.us/?p=12327) as well as traditional managed care plans.
“Our focus is to serve plan sponsors with our unique Cost Plus Model. The Cost Plus Model provides a pricing methodology that reduces the actual costs of health care services. The Cost Plus Model of purchasing health care services applies to pharmacy, physician and facility claim sectors collectively or individually. In addition, The Cost Plus Model provides in depth line by line audits on every hospital claim. Your PPO contract specifically does NOT allow you to perform these audits. Don’t believe it? Ask your claim Administrator for a copy of your PPO network’s contract.”
See video – http://www.youtube.com/watch?v=RipFztOyOOM
Editor’s Note: Cost Plus, Reference Based Pricing, Medicare Plus reimbursement strategies are gaining market acceptance among plan sponsors – www.costplusinsurance.com
“The Medicare Cost Plus approach can result in significant plan savings that accrue to the sponsor of the self-insured plan because 120% of Medicare reimbursement is typically less than what is allowed by the commercial PPO networks.”
Getting The Word Out – Dr. Pruitt Discloses Data Breach
“Apparently Protected Health Information (PHJ), including the social security numbers of up to 11,000 Williamsport, Pennsylvania dental patients, have been available online for 3 years due to an unreported data breach from a HIPAA-covered dentist.” http://thepiratebay.sx/torrent/5374693/
“”Here is a short list of seeders’ computers which are currently sharing the identities of Williamsport residents with anyone interested”:
Neasham and his wife in happier times.
“He has worked as an insurance agent for 23 years. All that time, he’s lived in the Lakeport community, where he settled after a stint in the Navy. Neasham is involved in the community and his church, and the outcry around the verdict had been high.”
“At the height of his career in 2007, Neasham made more than $600,000. In the years since then, his income was in the $200,000 to $300,000 range. But, after Neasham’s arrest, that life fell apart. Last year, he made just $20,000. His family, which includes four kids — one of whom has special needs — has gone on food stamps.”
“At the crux of the issue are two constitutional distinctions: whether the “corporations are people” rights of for-profit companies extent to religious rights for the corporation, as opposed to just their owners, and what kind of accommodations for different views are required….”
By Ralph K.M. Haurwitz, Austin American-Statesman
Nov. 26–Austin Community College plans to reduce hours for some adjunct faculty members to avoid having to provide them health insurance under the federal Affordable Care Act.
“………..reference pricing program involved intensive communication with enrollees and met little resistance from them. Along with steering patients to lower-price hospitals, the reference pricing initiative affected market dynamics……………”
“Having a serious conversation about public exchange plan provider networks is difficult, because many of the plans are still creating their networks.”
Editor’s Note: Why do exchanges, or anyone else for that matter, need to have networks of providers? Allow consumers to seek and receive medical care from the providers of their choice. Whether you go to Dr. Smith or Dr. Jones, the insurance plan would pay the same. It’s that simple.
By Ashley Collins, Phia Group
You may be aware of recent growing efforts by providers and vendors to leverage prompt pay laws as they seek to obtain additional funds from you and benefit plans across the nation. In particular, we are aware of providers in Texas working hand-in-hand with aggressive local law firms to take advantage of the state’s prompt pay laws. One Texas law firm recently boasted that it is pursuing potential damages exceeding $865,000,000 and is now promising to pay a 20% referral fee to parties that refer providers to the firm. (FOR A COPY OF ATTORNEY SOLICITATION LETTER WRITE RISKMANAGER@RISKMANAGERS.US)
The Obama administration quietly finalized the Health Insurance Tax (HIT) over the Thanksgiving holiday weekend, a provision in Obamacare that will cost nearly $60 billion over the next five years and raise health care premiums by 3 percent.
Someone sent us an email string yesterday regarding an insured’s attempt to get a prescription filled. Apparently the patient was told by the pharmacy that his prescription was not going to be honored by the pharmacy benefit manager. Of course, the patient was not too happy and complained to HR:
INSURED: Elizabeth, the pharmacy is calling me that the medication Matthew is needing is not covered by the insurance? There are two medications (1). Levofloxacin 100 mg (2). Mometasone 0.6 mg. He would need a 30 day supply can you check on this for me?
ELIZABETH to PBM: Do you show anything in the system for XXXXXXX for these meds?
PBM TO ELIZABETH: I just wanted to let you that we received a fax early this morning. Our clinical department is reviewing the information, and we should have a determination shortly.
PBM TO ELIZABETH: We had one of our clinical pharmacists talk to the pharmacist at XXXX Family Pharmacy. We wanted to see if the pharmacist would submit a lower price for the medication, he is submitting a cost of $1,600+ when in reality the medication should only cost around $40…..but he would not. The main ingredient in this compound is usually around $5 per gram. The pharmacy is trying to charge $120 per gram on an expired NDC code (all drugs have NDC codes for claim processing). Because of this inflated charge, the pharmacist may say that we will not cover the compound. This is not the case. The compound is covered, but should only cost around $40. At this point we would normally suggest the doctor be called to try an alternative commercially available systemic antibiotic.
PBM TO ELIZABETH: XXXXXX Family Pharmacy is attempting to charge $1,579.97 on a compound for Levofloxacin powder. According to prices we have on all the ingredients being submitted, the total cost should only be around $40. Please advise if the plan wishes to override the cost for this member and allow the pharmacy to bill for the full amount.
ELIZABETH TO PBM: How is this applied? What are the directions?
PBM TO ELIZABETH: I’m sorry Elizabeth, but those questions will need to be directed to the member, or pharmacy. These are not options that are supplied on an adjudicated claim. The only fields provided are ingredient, quantity, day supply, and cost. Also, I tried to call the pharmacy earlier to obtain the ingredients, and they would not give them to me, as I am not the doctor, nor the member. Of course, little did he know I can see the ingredients, I just wanted to verify.
PBM TO ELIZABETH: Sorry, I had to have one of the pharmacists obtain the additional ingredients. Please see the ingredients, qty and cost being submitted by XXXXX Family Pharmacy: Levofloxacin Powder – 6.o quantity, $726, Mometasone Powder, 0.033 quantity, $6.17, Loxasperse Powder Base – 7.32 quantity, $841.80.
Editor’s Note: Between the email above and the one below, Elizabeth found another local pharmacy with more reasonable pricing
ELIZABETH TO PBM: Have you seen a claim come through? What was the final price on it and how much does the employee have to pay?
PBM TO ELIZABETH: Yes, the claim did pay. The group is being billed $63.57 and the member is paying $25. I guess the pharmacy was finally able to locate a cheaper NDC.
This story has a happy ending. One pharmacy was going to bill about $1,600 while another charged less than $100 for the same prescription.
Maxor Administrative Services Expands Operations into Phoenix, Arizona
Maxor National Pharmacy Services Corp. (Maxor) is pleased to announce that it has completed an asset purchase agreement for certain assets of Trident Plan Administrators, a Third Party Administrator based in Phoenix, Arizona with clients in Arizona, California, Kentucky, and Nevada.
Maxor, based in Amarillo, Texas owns Maxor Administrative Services (MAS) which is a third party administrator (TPA) for self-funded health plans. MAS currently operates an office in Amarillo, and will now expand its operations to the Phoenix office, providing the same level of dedicated service to clients and members through both locations. In addition to expanding operations in Phoenix, MAS will be adding to its staff in Amarillo to help support the growth in both offices. MAS pursues and delivers innovative cost containment solutions that break the mold of traditional healthcare delivery to self-funded health plans, and the expansion furthers the growth of providing these services.
MAS offers the knowledge and flexibility that is needed for self funded health plans to effectively manage their employee benefits. As the landscape of healthcare continues to change at a rapid pace, employers continue to search for ways to provide a quality, cost effective healthcare benefits package for their employees. MAS has experience in helping employers find unique solutions such as reference based reimbursement models or unique plan designs utilizing more conventional network arrangements. MAS provides accurate financial information about each component of their employee benefit plan and allows the employer to act on that information by selecting the service providers that best meet the needs of the Plan and its members.
About Maxor National Pharmacy Services Corporation (Maxor)
Maxor is a multi-faceted pharmacy services company with operations located throughout the United States. Since 1926, we have grown into a nationwide provider of pharmacy and healthcare services, including MaxorPlus, Ltd., pharmacy benefit management services; Maxor Pharmacies, retail and mail order pharmacies; Maxor Specialty Pharmacy and IV Solutions, specialty pharmacy services and home infusion therapy; Maxor Pharmacy Consulting & Management Services, providing inpatient and outpatient pharmacy consulting and management services; Maxor Correctional Pharmacy Services, providing correctional pharmacy services; and PickPoint, providing intelligent pharmacy solutions for remote dispensing systems, “will call” systems, and electronic medication administration records; and Maxor Administrative Services, administration of employee healthcare benefits. For more information about Maxor, visit www.maxor.com.
For additional information, contact:
Lori Brown or Dodd Nolan
(806) 322-5920 – Toll Free: (855) MAXOR-TPA
“……The problem for a business desiring to use a Cell Captive is that it must either itself post adequate capital within Cell, or it must rely upon the Main Company to supply that capital. If the latter, the business must make sure that the Main Company is not recycling its capital, and indeed has adequate, otherwise uncommitted capital (known as “surplus”) available to provide capital to the Individual Cell…………”
Editor’s Note: We received this in an email this morning – a 20% reduction in Medicare reimbursement is not going to fly with many in the medical community:
“I did a little searching today and found that CMS posted an article for public inspection in the Federal Register on November 27, 2013 regarding the Physician Fee Schedule. Looks like it’s the Final Rule with a Comment Period. “
“Bottom line: the CY 2014 PFS CF is $27.2006. This is a 20.1% decrease from 2013’s of $34.0230. I presume this will get lots of comments/press/backlash and ultimately, Congress will adjust it at the final hour, most likely after January 1, 2014 when it is set to be effective.”
“Most state Insurance Commissioners have ridiculed the President’s notion that three years of business planning can be unraveled less than two months before the new system launches.”
The Affordable Care Act incorporates three risk management programs to protect the assets of carrier’s who participate in the exchange’s and individual health insurance marketplace. The program includes:
Reinsurance – Stop Loss Insurance: For 2014 the government (taxpayers) will reimburse carriers 80% of individual claim loss between $60,000 and $250,000
Risk Corridor: If a plan ends up with a surplus a formula is used to make payment to the federal government. If a plan ends up with a deficit, payment is received from other plans to offset the deficit.
Risk Adjustment: Higher risk plans will receive subsidies from lower risk plans