Archive for May, 2016

Taking PPO’s Into The 21st Century

Tuesday, May 31st, 2016

ppppooo

“In response to the continued relentless rise in health care costs, Insurers are taking a long, hard look at the value PPOs deliver versus their ability to contain medical costs.

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The Cost of Convenience

Monday, May 30th, 2016

ppoo

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Memorial Day 2016

Sunday, May 29th, 2016

 rusreberg

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.

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Billed Charges vs PPO Allowed Charges vs Cost Plus Insurance

Thursday, May 26th, 2016

cost plus

By Bill Rusteberg

A random sampling of hospital / facility claims incurred in the Lower Rio Grande Valley, Texas (The Valley) illustrates the crazy world of health care pricing strategies.

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Dereliction of Fiduciary Duties Triggering DOL Investigations

Thursday, May 26th, 2016
bernie

“The penalties for this type of fraud should be severe. All benefits leaders and their consultants should be overhauling how they manage care and cost, or risk the consequences. It’s particularly notable that the Department of Labor is now arguing that fiduciary dereliction in health benefits is rampant.” – Brian Klepper

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Annual Healthcare Costs For Families Hit $25,000

Thursday, May 26th, 2016

As health care costs escalate, Cost Plus / Reference Based Pricing plans gain traction within the employer community…………….

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Moving Patient Payment Upfront

Tuesday, May 24th, 2016

highdeductibleHospital systems are beginning to screen patients in high-deductible plans for their propensity to pay. And for those who can, they are developing systems to collect in advance of care.

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New Approved FDA Drug Costing $1 Million A Year?

Sunday, May 22nd, 2016

cigarette1

More and more employers are eliminating specialty drug coverage entirely. They really have no choice.

Imagine a small employer group of 250 employees assuming outright the risk of $1 million for Smoker Smith who now has lung cancer and is taking one of the new specialty drugs costing $85,000 per month. There is no way for the employer to continue his group medical plan. 

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The OPEC OF Healthcare

Saturday, May 21st, 2016

dendy

Mike Dendy, MBA, MHA

“OPEC laughed at the US and the rest of the world when we complained that $120 per barrel oil was choking the life out of business and the public in general around the world.  Rather, they built ski mountains in their deserts out of the rest of the world’s money and threatened to drive oil prices even higher. ”  

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HealthSmart Announces New CEO of BridgeHealth

Saturday, May 21st, 2016

healthsmart ge

(May 17, 2016)—HealthSmart announced today that Mark Stadler has been named CEO of BridgeHealth, effective June 1, 2016. Mark joined HealthSmart in September 2011 and has been the leader in our commitment to price transparency and empowering our members to become savvy healthcare shoppers.

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David Belk

Thursday, May 19th, 2016

belk David Belk, M.D.

Hello. It’s time for another chapter on the many ways in which our health care system is a total mess.

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Surge In Drug Prices Zinging Some Health Insurers

Thursday, May 19th, 2016

drug12

In an Oct. 5 report, The Wall Street Journal noted that prices for the 30 best-selling drugs last year had gone up an average of 76 percent since 2010 – eight times faster than general inflation.

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Plan Sponsor Guilty of Breach of Fiduciary Duties?

Thursday, May 19th, 2016

horseSome plan sponsors hire a third party administrator to manage costs. Others hire third party administrators to process claims.

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Highmark Sues U.S. Over Affordable Care Act

Wednesday, May 18th, 2016

indiangiver

“All we’re asking is for the federal government to do what they promised” – David Holmberg.

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Low Cost Software Tool for Medicare Reimbursement Strategies

Tuesday, May 17th, 2016

rbrvsNeed a low cost Windows solution for creating and managing Medicare and other RBRVS based fee schedules?  Try RBRVS EZ-Fees…….

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Blue Cross Blue Shield Enrollment Office

Tuesday, May 17th, 2016

bcbsenrollmentoffice

Blue Cross mobile enrollment office – when gas was 17 cents, and health insurance was affordable

Playing Doctor

Monday, May 16th, 2016

playingdoctor

In a deep dark recess of today’s Federal Register, large corporations just quietly received permission to “play doctor” with their employees.

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Cash Pay Plans Make Sense

Monday, May 16th, 2016

flying

“Those who say Cash Pay Plans are pie-in-the-sky dreams are mistaken. If man can fly then so can Cash Pay Plans.”

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Nothing Makes Sense In Health Care Financing

Monday, May 16th, 2016

confused“In the world of group health insurance, in order to reach the best financial outcome, you often have to depart from the realm of logic, reason and actuarial principles.”

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BREAKING: High Court Punts On ACA Birth Control Battle

Monday, May 16th, 2016

birthconbtrol

Will Religious Institutions Be Required To Fund Against Their Will?

By Jeff Overley

Law360, New York (May 16, 2016, 10:35 AM ET) — The U.S. Supreme Court on Monday sent a long-running battle over the Affordable Care Act’s contraception mandate back to lower courts, directing the Obama administration and religious nonprofits to work out a compromise.

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Is HealthSmart For Sale?

Friday, May 13th, 2016

mulebriar

Is HealthSmart TPA for sale? Word on the street says it is so.

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Texas Gets 1115 Waiver Extension

Friday, May 13th, 2016

waiver

Hidalgo County health officials breathed a sigh of relief after the federal government last week extended the state’s 1115 Waiver program that provides hundreds of millions of dollars for health care services throughout the county.

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Multi-Tier Provider Networks

Wednesday, May 11th, 2016

curtain

“Multi-Tiered provider networks will work best if an employer creates their own proprietary network on a direct basis rather than rely on third party intermediaries. Here is how it would work: Area providers are invited to enter into direct agreements with ABC Fence Company. They are given three choices: Tier 1 – 100% of Medicare, Tier 2. 125& of Medicare and Tier 3. 150% of Medicare. Plan participants who use Tier 1 providers pay less out-of-pocket than if they had used Tier 2 providers. Using Tier 3 providers would take economic courage.”  – Homer G. Farnsworth, M.D.

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Rx Clawback Scheme Fleeces Customers

Tuesday, May 10th, 2016

clawback

Companies are charging copays that exceed the customers’ costs for their drug. Pharmacists call it a clawback – the company is essentially clawing back money from you and, our source tells us, you probably don’t even realize it’s happening. “They have no idea,” the pharmacist says.

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Austin Texas Pharmacy – “We Don’t Deal With Insurance Companies”

Monday, May 9th, 2016

MedSavers Pharmacy

Medsavers Pharmacy is a family owned and operated pharmacy in Austin, Texas founded in 2005 on the principle: “we don’t deal with insurance companies.”

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Wellcentive – Transitioning to Value Based Care

Monday, May 9th, 2016

wellcentive

Quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care.

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Shifting Risk To Hospitals & Physicians -Episodic Bundled / Fixed Pricing

Monday, May 9th, 2016

bundledpayment

As Medicare and private insurers continue to struggle with implementing accountable care organization- and population-linked payments, an increasing amount of attention is being paid to a less expansive but almost as complex method of shifting risk to hospitals and physicians: paying a fixed price for an episode of care, or bundling.

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Continental Benefits – The Purple Cow

Monday, May 9th, 2016

purple cow

Continental Benefits is one of the fastest growing TPA’s in the United States. Founded in 2013 this national TPA is committed to reducing health care costs 25% and more. And they are doing just that.

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Changes At Maxor

Sunday, May 8th, 2016

maxorpharmacy

New CEO takes charge………….Maxor to exit correctional pharmacy services?

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Ruben Edelstein

Saturday, May 7th, 2016

edelstein

By Bill Rusteberg

Ruben Edelstein practiced managed care in his own way. The son of immigrants, he ran a successful furniture business in deep South Texas. An astute businessman, he grew the business with locations throughout the Lower Rio Grande Valley.

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Anthem CFO To Resign

Friday, May 6th, 2016

resign“The timing of DeVeydt’s resignation may “generate uncertainty among investors until fully understood”

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Crazy World of Health Care Pricing

Thursday, May 5th, 2016

southwestairlines

Why should you pay more to go to The Valley than the knuckle head sitting next to you?

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Aetna Selfies

Thursday, May 5th, 2016

Enter Aetna, which is making its foray into this space with “Aetna Funding Advantage,” available to groups with as few as 10 employees.

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Businesses Opting For Freelancers To Dodge Government Punishment

Tuesday, May 3rd, 2016

freelance“Spurred by competitive demands for more agile organizations, the world of work is pivoting to a blended workforce………..nearly 40 percent of top performing firms already have more than 30 percent of their labor force composed of contract/freelance workers.”

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County Demonstrates Political Courage To Challenge Local Provider Community

Sunday, May 1st, 2016

bot“The leadership of Botetourt County has, like many municipalities, been searching for innovative ways to reduce their health costs without increasing deductibles and co-pays to the members….”

Botetourt County, Virginia and San Patricio County, Texas have something in common – the political will to seek innovative strategies to rein in ever increasing, tax payer supported, health care costs for their employees. Challenging the status quo within their respective local health care community takes a rare political courage to prevail – Bill Rusteberg

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