Montvale Surgical Center v. New Jersey Health Benefits Commission

onesixtyThe issue in this case was whether a New Jersey government agency should pay an ambulatory surgical center out-of-network health care benefits at 160% of the Medicare rate, rather than, as required by statute, a rate determined by a “nationally recognized database.”

“There are very few market forces that limit what an out-of-network provider can charge. For that reason, non-participating providers are often reimbursed significantly more than their in-network counterparts.”

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Cost Plus Insurance: New Reality In Provider Payment Models

cost plusProviders 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……….Given their growing popularity, Providers need to be proactive in understanding and managing these types of programs.

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Will Accountable Care For Medicaid Work In The Ghetto?

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Patients might only be able to get to a doctor during the day on the weekends because it’s too dangerous in the neighborhood to be going out at night……The patient goes to the pharmacy but is told the new medication requires pre-approval.  The patient doesn’t know what to do so the patient goes to smoke a cigarette…………...

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San Antonio Runs Off Uber, Now Texas Uberizes Telemedicine?

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The City of San Antonio, through punitive restrictions on free trade has run off Uber from the city effective April 1. Now the State of Texas, through special interests, runs off telemedicine companies too? What has happened to traditional Texan values of hard work, innovation and freedom to conduct commerce?

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Connecticut Fee Schedule for Hospitals, ASCs Takes Effect

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Connecticut’s Medicare-based fee schedule for workers’ compensation takes effect April 1.

The new fee schedule pays 174% of Medicare for in-patient care, 210% outpatient care and 195% for ambulatory surgical centers.

This is touted as a cost savings measure. Does this mean prior to April 1 Connecticut hospitals and ambulatory centers were getting more?

So much for managed care contracts these days and another reason why Cost Plus Insurance, Medicare Plus reimbursement schemes are taking the market by storm. Payers are “mad as hell and not taking it anymore……” – Homer G. Farnsworth, M.D.

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Health Insurance Brokerage: Lowest Pricing Drives Sales in Fully Insured Market

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By Homer G. Farnsworth

Does it matter how good you service a fully-insured account, or how long you have had it? Under the PPACA the answer is “probably no.” Low price has become the determining factor between success or failure in retention of business in today’s fully-insured market.

Most brokers remaining in the fully-insured market live or die on rates alone.

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Allstate Wins $46 Million Judgement In RICO Suit Over Health Claims

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By Kurt Orzeck

Law360, New York (April 08, 2015, 9:35 PM ET) — A New York federal court on Wednesday entered a $45.7 million default judgment in favor of Allstate Insurance Co. and other insurance companies in their Racketeer Influenced and Corrupt Organizations Act suit alleging a vast money-laundering conspiracy to bill for fraudulent health claims.

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Former Benefit Consultant Offers Innovative Partnership Opportunity

Benefitsally

We partner with innovative benefit consultants and employers to bring intelligent healthcare solutions to the table. These solutions are cost-cutting opportunities for mid-sized companies – regardless of industry – that are easily implemented into existing benefit plans.  http://www.benefitsally.com

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San Benito ISD Rejects TRS ActiveCare – Seeks Insurance Consultant

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San Benito – Home of Baldemar Garza Huerta (Freddy Fender)

In a special called school board meeting (http://board.sbcisd.net/wp-content/uploads/2015/03/s033015.pdf ) on March 30 the San Benito Independent School District rejected the administration’s recommendation to join the TRS ActiveCare plan.

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RiskManagers.us Wins Insurance Contract

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San Antonio, Texas  RiskManagers.us, a specialty company in the benefits market that works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods has been awarded a $10,000,000 insurance contract by the City of San Antonio.

“We are pleased to make this announcement today and look forward to a long and rewarding relationship with the City of San Antonio,” stated company spokeswomen Molly Mulebriar.

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