Prime Healthcare Acquires Mission Hospital

prime1Prime Healthcare’s strategy is to take over struggling hospitals and cut out the least lucrative or money-losing services. Prime often cancels insurance contracts at its newly acquired hospitals, enabling it to charge the insurers higher rates for treating their members…..

See: http://www.latimes.com/business/hiltzik/la-fi-hiltzik-prime-feds-20160717-snap-story.html

Continue reading Prime Healthcare Acquires Mission Hospital

Fifth Circuit Holds That ERISA Preempts Provider’s Promissory Estoppel Claims

LIED

This case offers insight into how promissory estoppel may play a role where a provider seeks reimbursement from an ERISA plan.

Houston Metro alleges that before it provided medical services to any patient, it sought and “received verification by telephone from Defendants that each patient was covered by a health benefit plan,” and “that the particular procedures were covered by the health benefit plans and would be paid in accordance with the health benefit plan.”  Houston Metro alleges that it would not have provided the services if the defendants had not made these statements.

Continue reading Fifth Circuit Holds That ERISA Preempts Provider’s Promissory Estoppel Claims

21 Things To Know About Balance Billing

smile

Reference Based Pricing Rocks!

The following article is entitled “20 Things To Know About Balance Billing.”

We added one more.

There is only one market strategy that protects consumers against balance billing – Reference Based Pricing (RBP) plans. Traditional managed care plans provide absolutely no protection against balance billing – consumers are on their own when they get one. Not so under RBP plans.

“In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.”

Consumer Union also reported 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn’t know their rights to fight the bills.

“So many times, people just give up [in surprise billing disputes],” Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR.

Which plan would you rather have? A traditional managed care plan with limited provider choice, ever increasing costs and balance billing liability. Or a Reference Based Pricing plan with lower cost, better benefits, unlimited choice of providers and balance billing protection? The choice has never been more clear………………..

Continue reading 21 Things To Know About Balance Billing

What!……….I’m Going Back To Sleep!

ripvan

Waking up is hard to do. I’ve been trying for years. Even nightmares couldn’t wake me up until yesterday when I had a horrible one that lit me up like a Roman Candle. I shot out of my hiding place, raced to the library and found the 2017 Milliman Medical Index report. “Its true, its true, this is not another nightmarish dream, its true!” assured the sweet librarian.

“But it can’t be” I screamed. When I went to sleep in 1973 health insurance rates of $17 for individuals and $35 per month for family coverage were considered competitive! What the hell happened?”

“Government got involved, managed care contracts memorialized collaborative schemes to defraud consumers into thinking they were getting great “discounts” when in fact they were assured of paying more year after year, hospitals took lessons from used car salesman and invented something called a Charge Master, and health care supply chain managers (insurance brokers, agents and consultants) were tasked, and they accepted their role to make sure the new status quo remained forever” said the librarian with head hanging low and slumped shoulders.

“They say the only way to fix this is more government control through a single payer system. Go figure!” she continued. “I’m moving to Communist China where the free market in health care is alive and well!”

Continue reading What!……….I’m Going Back To Sleep!

Pittsburgh Teachers Thwart Healthcare Stealing From Education

Branson

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson (Basic tenet of RiskManagers.us )

At long last, forward-looking school and union leaders recognize they share the same goals and are proving that it’s not that difficult to slay the healthcare cost beast even in an expensive and contentious healthcare market.” – David Chase

Editor’s Note: As Texas school districts struggle to maintain affordable health care for their employees, Pittsburgh and other school districts around the country are actually achieving health care cost reductions while improving benefits at the same same time. Instead of trying the same old strategies of the past, these districts are applying common sense solutions that work. Everyone wins; the consumer, medical providers and plan sponsors…………………….

Continue reading Pittsburgh Teachers Thwart Healthcare Stealing From Education

Attention Insurance Producers: Join Us And Earn Millions!

omg This beats this! – BCBS To Pay $50,000 Broker Sales Incentive Each Fully Insured Group Sold

We have previously executed a similar strategy with a prescription benefit management company, Partners Rx (PRx), which we sold for $100,000,000 to Magellan Health in 2013.  That sale resulted in many producers receiving $1 million to over $4 million.  We anticipate that this opportunity will be even more lucrative.

Continue reading Attention Insurance Producers: Join Us And Earn Millions!

Tell Us Your Outrageous Health Care Stories

 klepper

By Brian Klepper

Dave Chase, who has been our most eloquent teller of health care craziness stories in recent years, sent out a request the other day for alarming stories from the broker/consultant sector. He wrote:

Benefit brokers get paid more for doing a bad job (i.e., allowing healthcare costs to go up pays them more since they make a % of costs in many compensation schemes). They can get rewards for driving up spending such as trips or other undisclosed compensation. Tell us some of the most outrageous compensation schemes that help fuel hyperinflation in healthcare.

Continue reading Tell Us Your Outrageous Health Care Stories

Patients Are Flocking To Urgent Care Clinics – Now Hospitals Are Too

urgent12

The clinic business model is straightforward and attractive: Treat as many patients with minor injuries and illnesses as quickly as possible—usually in 30 minutes or less………..A typical immediate-care center sees 294 patients each week, a number Kalorama predicts will grow for the next four years. Per-site revenue is expected to increase to nearly $1.7 million by 2021……….

Continue reading Patients Are Flocking To Urgent Care Clinics – Now Hospitals Are Too

Will State Employee Health Care Fix Hurt Texas Medical Schools?

medicalschool Medical School Students

Raise your hand. Which one of  you wants to treat Trooper Jones? He’s in the lounge with a cold………………..

Inserted in the nearly 900 page Senate budget bill are three paragraphs that would force the medical schools to treat members of the Employees Retirement System of Texas at a discounted rate.

Continue reading Will State Employee Health Care Fix Hurt Texas Medical Schools?

“ERISA Fiduciary Largest Undisclosed Risk I’ve Seen in My Career”

davidchase 

Another Excellent Article By David Chase

Employer/union provided health benefits likely represent over two-thirds of industry profits as they wildly overpay for healthcare services due to the misperception that PPOs help save them money. In reality, PPO networks cost employers/unions dearly.

Increased outside scrutiny on how ERISA-regulated health plans spend their dollars could create immense potential liability for both company directors and health insurers across the country. 

Continue reading “ERISA Fiduciary Largest Undisclosed Risk I’ve Seen in My Career”

Implementing RBR “Done Right”…Begin with Diligence

mcs

“It is my belief that any TPA or Advisor using this list of questions as a tool to evaluate options will be able to easily differentiate the pretenders, professional marketers and conscientious vendors offering a well-designed, well-supported offering.  Such differentiation is critical to the continued development of the RBR approach and disruption of traditional PPO use.” Glenn McLellan

Continue reading Implementing RBR “Done Right”…Begin with Diligence

David Contorno – Status Quo’s Worst Nightmare

david111q

“Trusting carriers to manage your healthcare spend is like trusting American Express to manage your corporate expenses. We all know Amex gets a percentage of all charges, so if they had their way, employees would charge anything and everything on it. After all, the employer pays the bill. Wait, same with health insurance. They make a vig (the interest on a shark’s loan) on every claim and the employer pays the bill…..” – David Contorno

Continue reading David Contorno – Status Quo’s Worst Nightmare

LevelFunded Health

levelfundedh

LevelFunded Health is a national, direct to employer distribution platform focused on level and self-insured benefit programs for small to mid-size employer groups. For businesses with employees ranging from 50 to 1,000; it can help to immediately save these businesses anywhere from $50,000 to $2 million per year on healthcare costs, while simultaneously improving benefits.

Continue reading LevelFunded Health

South Texas Physician Becomes TMA President

cardenas

He helped lead TMA’s fight for medical liability reform, which became Texas law in 2003.

“When you get shot at all the time, when 70 percent or more of your colleagues are named in a lawsuit or a party to a lawsuit and you can no longer recruit, retain or attract [physicians] to your community to do what needed to be done for the health of your community, something had to change,” Cardenas said. “That was something that drove me and others in our community to stand up and say, ‘No more.’ We came together and organized.” – Carlos J. Cardenas, M.D.

Continue reading South Texas Physician Becomes TMA President

GOP’s Bill Is Still Government-Run Health Care

bride

Remember in 1966 when Medicare was passed into law? Republicans stood by their principles and were united against this move to “socialized medicine.” They fought hard to stop the measure. Now you can’t find one Republican against Medicare. One’s principles go by the wayside with the absence of term limits. The same will hold true in America’s irreversible move to a single payer system.

“The only difference between Republicans and Democrats is Republicans take just a little bit longer to get there” – Bill Rusteberg

Continue reading GOP’s Bill Is Still Government-Run Health Care

A New Blog for Employer and Union Benefits Managers and Their Advisors

klepper Brian Klepper

Reading yet another excellent post on an important topic – PPOs in this case, see below – by South Texas broker Bill Rusteberg  the other day, I was struck that there are few go-to sites dedicated to the very significant challenges faced by health benefits managers, consultants and other health benefits professionals…………………

Continue reading A New Blog for Employer and Union Benefits Managers and Their Advisors

Off The Record

hay adams

By Bill Rusteberg

While visiting Washington DC this week I ended each day with a short visit to Off The Record, a bar located at the Hay Adams Hotel across the street from the White House. This place is always packed with interesting people and I had occasion to meet a few of them. 

Sitting at the bar one evening I struck up a conversation with a fellow to my left. His name was Johnathon Moulton, son of the late R.E. Moulton, one of the nation’s leading stop loss insurance intermediaries of his time. To the right of me was Mike………………

Continue reading Off The Record