More Providers Are Leaving PPO Networks……And Suing

angrydocOver the past decade, there has been a significant increase in the number of physicians who have dropped out of Preferred Provider Organization (‘‘PPO’’) and Health Maintenance Organizations and have attempted to negotiate their own reimbursement schedules. With this growing trend we are beginning to see a wave of provider lawsuits begging for larger reimbursements.

Continue reading More Providers Are Leaving PPO Networks……And Suing

The PPACA – Game Changer for Health Care Financing

The Affordable Care Act (ACA) has had a fundamental impact on health care financing in this country. It has effectively provided added incentives for plan sponsors to consider modified self-funding arrangements for their employee health and welfare plans in lieu of fully-insured plans. The advantages of doing so are clear.

Continue reading The PPACA – Game Changer for Health Care Financing

Hospital Contracts Made Simple – 120% Method

monkey Sam Crafting, M.D.

Sam Crafting 120 Hospital Contract For RiskManagers.us

By Bill Rusteberg

Hospital contracts, if you can get your hands on one, may prove too complicated for most. Page after page of legalese followed by five or six pages of reimbursement schedules makes for dull reading. On occasion one will be delighted to discover that some payers utilize a simplified, shortened version that even monkeys can understand.

Continue reading Hospital Contracts Made Simple – 120% Method

Blue Cross Subsidiary Touts Cost Plus Insurance

acs-cost-plus-sheet

Click for an Informational Video ←

ACS Benefit Services Inc. , a wholly owned subsidiary of BCBS of North Carolina, is a third party administrator active in marketing and administration of Referenced Based Pricing, Cost Plus Insurance plans.

“How does ACS Benefit Services Cost Plus pricing compare to BCBS North Carolina’s PPO pricing?” – Molly Mulebriar

Continue reading Blue Cross Subsidiary Touts Cost Plus Insurance

Keeping Up With New Payment Models: “Cost Plus” or “Medicare Plus”

katz

“Providers across the country are experiencing a new “reality” in payment models where patients are presenting “Medicare PLUS” or “Cost PLUS” insurance cards, the latest tactic of self-funded, commercial employee benefit plans…….We’ve seen reimbursement levels range from 110% to 140% of Medicare….”

Continue reading Keeping Up With New Payment Models: “Cost Plus” or “Medicare Plus”

Eliminating Third Party Profit Stacking In Health Care

hpc

“HPC has developed a “dream team” of highly experienced medical claim negotiators and nurses………Future products include buying or building a PBM for our clients and operating it at cost. The goal is to shift the profits from PBM’s to Payers and their clients in the same way that we are doing with Large Dollar Claims.”

Continue reading Eliminating Third Party Profit Stacking In Health Care

Darwin Award Study Exposes Sex Differences In Risk Taking

streesed

Sex differences in risk seeking behaviour, emergency hospital admissions, and mortality are well documented. However, little is known about sex differences in idiotic risk taking behaviour………..Idiotic risks are defined as senseless risks, where the apparent payoff is negligible or non-existent, and the outcome is often extremely negative and often final.

” It is conceivable that the sex difference is attributable to sociobehavioural differences in alcohol use. Anecdotal data support the hypothesis that alcohol makes men feel “bulletproof” after a few drinks….”

Continue reading Darwin Award Study Exposes Sex Differences In Risk Taking

AMPS Acquires Claims Delegate Services

aaaaa

“Our clients are often speechless when we document what they are paying for hospital services after what they believe are the PPOs discounts…………………..On average we find payment levels of over 260% of Medicare and many times we find post PPO payments greater than 400% of Medicare………….”

AMPS is the leading and fastest growing  Cost Plus / Reference Based Pricing company in the United States. Quick to react to market demands  ( Xerox, Eastman Kodak And Cost Plus Insurance )  AMPS provides competitive pricing coupled with superior service.

“Companies must work constantly to eliminate any cost factor that does not add value to a business process” – Mike Dendy

Continue reading AMPS Acquires Claims Delegate Services

Local Government Strategies to Address Rising Health Care Costs

Summary:
Rising costs over the last decade have prompted many local governments to make changes to their health plans and strategies. Cost sharing, wellness program, and disease management initiatives are widely reported. Other changes cited include increased reliance on high-deductible plans, dependent eligibility audits, and altering retiree benefits.

Continue reading Local Government Strategies to Address Rising Health Care Costs

Another Point of View (To Preceding Post)

I understand that you have very prestigious degrees and that this is a 5 year old post. However, this is why I felt compelled to comment. You should have known to prepare better, and this shouldn’t have been up for this long.

While you may have the “General Concept”, you clearly lack the requisite knowledge to understand the details behind MAC pricing, or any drug pricing logic for that matter.

Continue reading Another Point of View (To Preceding Post)

Don’t Get Caught By PBMs’ MAC Mousetraps

big macFor most of the world, the letters MAC conjure up a Big Mac — the inviting super-sized hamburger that people love but enjoy at their peril.

But for health plans providing prescription drug coverage, the acronym represents an incomprehensible concept inserted into prescription coverage contracts by pharmaceutical benefit management companies (PBMs).

Unfortunately, unbeknownst to most health plans, this MAC is far more pernicious than any oversized hamburger. In fact, PBMs insert the MAC concept into contracts in three ways to relieve health plans of millions in savings that they would otherwise obtain from using generic drugs over branded drugs.

Continue reading Don’t Get Caught By PBMs’ MAC Mousetraps

Texas TPA’s Must File Annual FIN 486 Report

tdi

Texas TPA’s are required to file an annual report to the Texas Department of Insurance to include current financial statement, total number of plans and employee lives along with biographical affidavits of officers and controlling shareholders. The FIN 486 Report includes Exhibits A-E.

3 Carriers Control Health Insurance Market

Continue reading 3 Carriers Control Health Insurance Market

Sales – The Engine That Drives Economics

mulebriarBy Molly Mulebriar

Sales is a profession. It entails a multitude of disciplines. Coping with continuous rejection and fear ensures the profession a steady procession of former salesmen. Those who overcome these weaknesses thrive. They are among the top earners in the country.

A successful salesman knows how to handle rejection. He has no fear of cold-calling. He is an expert observer and critical thinker. His powers of deduction are keen. He understands the importance of body language. He is patient and self-motivated. He listens. He has empathy. He is a problem solver.

When I asked a seasoned salesman in San Antonio to what he could contribute as to the basis of his success, he said “Molly, there are four principles, that if applied consistently, will lead anyone towards a successful sales career.”

1. Establish your right to be there

2. Establish the need common to most

3. Establish specific needs

4. Offer a solution

Pace Of Health Care Cost Increases Falls To A 54 Year Low

really

Pace of Health Care Cost Increases Falls to a 54-Year Low

“The share of the economy devoted to health care, which appeared to be growing inexorably for decades, has been the same since 2009…. Spending for health care in 2013 averaged $9,255 a person … Health spending grew at about the same pace as the economy and accounted for 17.4 percent of the gross domestic product, which reflects the total output of goods and services.” (The New York Times; subscription may be required)