Sun Life Tops Market Expectations

November 9th, 2018

Business strategy is to focus on four pillars of growth: the Canadian home insurance and wealth market, US group benefits, global asset management, and distribution excellence in higher growth markets in Asia…………………………

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90+ Medications To Be Dropped by Insurance in 2019

November 9th, 2018

Drugs excluded includes brand-name drugs for which less expensive brand or generic alternatives are available in the market…………………………………..

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GR Data Insights: MSK – Quality matters………………

November 8th, 2018

Grand Rounds is focused on reducing high cost claimants and improving patient outcomes and we have tangible evidence to prove it……………………

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Here Comes The Judge

November 8th, 2018

 

 

He’ll give you time if you’re big or small
All in line for this court is neat
Peace brother, here comes the Judge 
Here comes the Judge…………………………………….

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Gridlock Sets In……………….

November 8th, 2018

With a Democratic House, a Republican Senate, and President Trump in the White House, get ready for two years of maneuvering but little progress on health care…………..

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State of Utah Fights High Drug Prices With Results

November 8th, 2018

The savings are anywhere between 38% to 75% well may save the state millions each year……..

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CMS Delays Dramatic Office-Visit Coding Changes Until 2021

November 6th, 2018

Proposed changes would have increased CPT 99213 by 30%……………..Primary Care Physicians lose out on pay raise. 

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November 4th, 2018

How do you know if your surgeon is the best of the best or the worst of the worst? Unfortunately most patients play Russian Roulette when it comes to picking one………………….the results can be hazardous  to your health…………..

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More Texas Doctors Switch To Concierge Medicine Model

November 4th, 2018

More doctors in Texas plan to make the switch to primary care out of frustration with the current healthcare system…………………………….

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Employers Are Becoming More Active in Healthcare Claims Management

November 2nd, 2018

“Employers are cutting out insurers completely and contracting directly with providers and/or creating near-site or on-site health clinics for primary care……………….More traditional cost management techniques are simply running out of gas. Employees, who have borne half of recent-year cost increases, simply can’t afford anymore,”

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San Patricio County Seeks Stop Loss Insurance

November 2nd, 2018

San Patricio County is seeking competitive specific stop loss proposals for a January 1, 2019 effective date. This 400 life case has been on Reference Based Pricing for the past ten years and does not access any managed care networks.

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Today’s Medical Students Lack Skills For Surgery

October 31st, 2018

New medical students have spent so much time on screens that they lack vital practical skills necessary to conduct life-saving operations, a leading surgeon has warned………………

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MedSave Management LLC

October 31st, 2018

MEDICAL BILL SOLUTIONS – A Medical Debt Resolution & Advocacy Services Company……

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Ballot Measure Limits Hospital Reimbursement To Cost +15%

October 30th, 2018

Voters in two California cities will decide two ballot measures that aim to curb healthcare costs, according to a Kaiser Health News report……………………

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Health Care Stole The American Dream – Here’s How We Take It Back

October 30th, 2018

RBP Quiz – What Level Of Benefits Will 100% of Medicare Buy?

October 30th, 2018

What level of benefits could one expect based on claim reimbursement of 100% of Medicare allowable charges? 

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Interview With Greg Everett, President of Payer Compass

October 30th, 2018

In this episode, The Phia Group chats once again with one of their Partners in Empowerment, Gregory S. Everett, President and CEO of Payer Compass.

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PBM Practices Exposed

October 28th, 2018

PBMs use arbitrary and opaque DIR fees to derive record profits at the expense of independent pharmacies, plan sponsors and most importantly consumers……………………..

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How We Are Getting Screwed…………………

October 28th, 2018

The healthcare industry is rife with secrets the healthcare industry doesn’t want you to know. If you have the courage to read this article, you may be wise to order The Schuessler Stick™, overnight delivery.

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70% of Americans Back Medicare For All?

October 28th, 2018

Medicare for all is only one election away. Opponents may win 1,000 wars but proponents only need to win one. But this author writes “Medicare for All’ will never work, so let’s stop pushing it.”

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Hospital Gouging Practices Exposed

October 28th, 2018

       Victor Lustig

Adam Conover explains hospital gouging practices 20 in this eye-opening 5-minute clip……..

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High Cost vs. High Quality: How Do You Navigate Health Insurance?

October 28th, 2018

By Dave Chase

The most persistent myth in healthcare is that high cost equals high quality. It’s a proposition that holds across a great many products that are bought and sold in actual, functioning markets — but that’s not a description that applies to the U.S. healthcare industry.

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Texas Man Scams TriCare For More Than $50 Million

October 28th, 2018

 

A Dallas man has admitted to defrauding a military health insurance program for $50 million.

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If You Can’t Beat Them, Join Them

October 28th, 2018

Blue Cross of N. Carolina has announced a new, no network health plan (Reference Based Pricing). Coupled with a high deductible, BCBSNC touts a 33% premium savings.

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County Sues Insurance Broker Over Secret $250,000 Commission

October 28th, 2018

The county’s complaint alleged broker accepted a $254,000 kickback for referring the county to a major insurer…………………in addition to fees paid directly by the county to the broker…………

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Trump Plans To Revamp Employer Based Health Care

October 28th, 2018

The Beginning Of The End of Group Health Insurance?

The proposal would allow companies to use HRAs to reimburse employees’ premiums on the individual health-insurance market……………………….In lieu of adopting a group medical plan for employees, an employer can give employees money to purchase individual health insurance in the open market....

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Pharmacy Owner Charged In $10 Million Health Insurance Scam

October 28th, 2018

An Alabama pharmacy owner has been charged as part of an alleged conspiracy to scam more than $10 million from a federal health insurance program………………

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If You Can’t Beat Them, Join Them

October 26th, 2018

Earlier this month we learned the state of North Carolina will be terminating their state health plan’s contract with Blue Cross and will instead adopt a Reference Based Pricing plan (Another State Adopts Reference Based Pricing Strategies). Now we learn Blue Cross of N. Carolina will be introducing a new, no network health plan, which is of course, Reference Based Pricing. Is this a case of “If you can’t beat them, join them?”

“It is normal comprehensive insurance, with a high deductible, and the main difference being that reimbursement is based on a ‘reference pricing’ approach similar to what state Treasurer (Dale) Folwell has recently proposed for the state employee plan…………….”

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HealthSmart

October 26th, 2018

Have you looked at HealthSmart lately? It’s an exciting time for us. We’ve had a busy year of growth, transition and powerful new solutions. Now more than ever, you should give us a look to see how we can help your clients and prospects. Read the rest of this entry »

Reference Based Pricing – Misconception #1

October 25th, 2018

Every day you remain in an RBP plan, your risk of massive liability increases

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I Don’t Care

October 22nd, 2018

“Why aren’t you gonna pay for my prescription! My doctor ordered it!!!!”

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Balance Billing Is A Plan Sponsor’s Best Friend

October 21st, 2018

“Balance billing only occurs when purchasing  goods or services without asking  the price.”

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Uproar at Purdue

October 18th, 2018

Employees upset with cost containment move by University officials………….“How long can we continue to offer health care coverage when we’re experiencing 20 percent to 30 percent increases on a regular basis?”

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KISS – Keep It Simple Surgery

October 18th, 2018

The KISx Card was created as a solution for self-funded employers to tackle egregious surgical pricing while bringing simplicity to the employee experience……………….

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Blue Cross Blue Shield IL Sued for Fraud, Robbing Chicago Taxpayers

October 17th, 2018

Working The Spread is nothing new. Seems quite common. The article below is about a lawsuit in which spread pricing is alleged.

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Email Solicitation – To Good To Be True? You Decide

October 17th, 2018

We get unsolicited emails every day like the one below. This one touts a plan we have never heard of before, offering what appears to be “to good to be true” pricing. We thought we would share this for our three readers…………………….

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Paying for Coverage Without Any

October 17th, 2018

“What are you talking about! That’s insane” cried the HR lady. …….”I thought you needed to know” I replied.

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Chinese Government Demanding Big Discounts from Drugmakers

October 15th, 2018

The power of large numbers, 1.379 billion Chinese, brings big benefits when negotiating with drug manufacturers…………………………….

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Many Agents and Brokers Are Still Uncertain About “REFERENCE BASED PRICING”

October 12th, 2018

Breaking The Status Quo

Allied National employer groups are proving beyond the shadow of a doubt that the Freedom Plan (our reference based pricing reimbursement) is a better, lower cost, solution than traditional PPO networks.

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South Texas Health Cooperative

October 12th, 2018

Rest Easy In Our Pool

Taming Health Care Alligators Since 1998

The South Texas Health Cooperative (STHC) provides affordable health insurance to member school districts since 1998. Through careful risk management strategies, the STHC risk pool has achieved lower and stable costs while improving benefits at the same time.

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Wow! What a Difference!

October 12th, 2018
Earlier this year I moved a client from a BUCA PBM to an independent PBM. No benefit or formulary changes were made. Now that I have mature credible claim data on the move from the BUCA PBM to an independent PBM, I find Rx claims have reduced 30.1%.

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Big News! FTC to Probe Hospital Contracts

October 11th, 2018

 

This may become the tipping point in health care reform. “The Senate Judiciary Committee chairman questions contract terms between insurers and hospital systems…………..contracts between insurers and hospital systems are limiting competition and pushing up health-care costs……………..”

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Gag Clauses Now Illegal

October 11th, 2018

In an effort to increase drug price transparency, President Donald Trump signed two bills into law that ban insurers from writing gag clauses into their contracts with pharmacists………………

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Texas Spanks Humana – Who’s Gonna Pay For It?

October 11th, 2018

Now let me get this straight. Humana tries and fails to negotiate a reasonable rate with enough in-network providers and is punished for it. Well, the solution is to get rid of the network and treat all providers as out-of-network. That’s what Reference Based Pricing plans do.……………..BTW guess where Humana is going to get the $700,000………………………..

– Bill Rusteberg

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Hospital Profits High In Indianapolis

October 11th, 2018

Hospitals in central Indiana enjoy a higher profit margin than those elsewhere because they overcharge insurers…………………..

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UMMC / BCBS Squabble

October 11th, 2018

The following article (Posted on Linkedin by Carl Schuessler) brings to mind deeper issues than the “surface” issues most consumers reading this will take away. The article hints of a gold mine of information leading to more questions than answers.

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We All Have Health Care Stockholm Syndrome

October 8th, 2018

“The Stockholm syndrome we have been suffering under is starting to break……………

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Another State Adopts Reference Based Pricing Strategies

October 5th, 2018

First it was Montana, a smallish state somewhere up north of us, who adopted Reference Based Pricing for their state health plan (Montana Adopts Reference Based Pricing Strategies). The little lady up north has big brass cojones! (Tough Negotiator Saves State Millions In Health Care).

Next there is California which is currently considering similar efforts. (California Assembly Bill 3087 Would Control Prices in the Commercial Market).

Now there is yet another state adopting Reference Based Pricing for their state employee plan. They must have heard about the little lady in Montana.

I thought Texas would lead the country on this. After all, several of us have been making noises in Austin over the past two years. Has Texas Lost It’s Cojones?.

– Bill Rusteberg

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Deductibles Hit $2,000 As Employers Intensify Cost Shift

October 5th, 2018

“Annual deductibles for Americans with employer-based health coverage are hurtling toward $2,000 on average, according to new studies analyzing employee medical benefits.”

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New England Journal of Medicine Slams Wellness Programs

October 4th, 2018

“Outcomes-based wellness programs don’t work, so why do them?  There is no upside and therefore no argument in favor of poisoning the doctor-patient relationship. “

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Employer-Provided Health Insurance Approaches $20,000 a Year

October 4th, 2018

Rising prices “chiefly tied to rising prices paid for health services.” Yet health care costs have remained essentially static for the past ten years. It’s the prices that have increased, not the cost of health care. – Bill Rusteberg

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San Antonio Emergency Room Raises Concerns

October 4th, 2018
San Antonio’s newest Emergency Room service sparks interest among residents and government officials.  The Emergency Room “is not even open for business but is already causing controversy.”

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Tough Negotiator Saves State Millions In Health Care

October 2nd, 2018

 Marilyn Bartlett

Marilyn Bartlett took a deep breath, drew herself up to her full 5 feet and a smidge, and told the assembled handful of Montana officials that she had a radical strategy to bail out the state’s foundering benefit plan for its 30,000 employees and their families………………..

Will Texas be next?

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An Electrical Physical? How Much Is That?

October 1st, 2018

“No, I am not doing an electrical physical, I’m here for a cold and I don’t need that test!” ……“But sir, your Blue Cross will cover it” came her soothing reply.

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Who Are A Status Quo Health Insurance Salesman’s Two Best Friends?

September 30th, 2018

If you are a status quo broker your two best friends are………………….

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Important Decision For Reference Based Pricing Lawsuit?

September 29th, 2018

This is a suit where the hospital alleged numerous claims against the RBP vendor and the RBP vendor responded with a motion to dismiss………………………..
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Dr. Hodad

September 28th, 2018

Every medical community has a Dr. Hodad (Hands of Death & Destruction). Peers never talk about Dr. Hodad for fear of lawsuits…………………………………………..

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Generic Substitute for $94,000 Drug To Be Released Jan. 2019

September 28th, 2018

Harvoni drug cost in the US for a three month, 84 tablet course of therapy, is $94,500. The same drug if purchased in India for example costs $900 for 3 months 84 tablet course………………

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HealthSmart Reference Based Pricing Strategies

September 27th, 2018

Our solution pays pre-negotiated rates to hospitals and facilities at various rates of Medicare pricing…..

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The End of The Health Insurance Carrier

September 26th, 2018

Health insurance carriers face slow but steady disintermediation by innovative next generation benefits advisers who are using alternative funding to take control of employer health plans and reduce costs………..the beginning of the end of these dinosaurs

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Anti-Deductible Health Insurance Plans

September 25th, 2018

The movement away from deductibles illustrates a growing sentiment that exposing patients to more out-of-pocket healthcare costs doesn’t solve the cost conundrum and could harm patients’ health…….

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TASA Hints At Potential TRS ActiveCare Changes

September 25th, 2018

The 86th Texas Legislature will convene on Jan. 8, 2019. While TRS cannot speculate on specific outcomes, the Texas Legislature may make changes to the health care program. If there are changes, we will notify our members in writing.

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Turning Bronze Into Gold

September 24th, 2018

Turning Bronze Plans into Gold Plans at Bronze Plan costs is a common but unspoken strategy……………but who is benefiting from “beating the system?”

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Three Victoria City Employees Criticize Proposed Health Insurance Plan

September 23rd, 2018

Employees’ medical claim expenditures have increased in recent years, causing the health fund to deplete so significantly that the proposed budget for the 2019 fiscal year allocates an additional $1 million for the health fund…………….

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You Can’t Fix What You Don’t See

September 22nd, 2018

candle

“We bid out our employee health insurance every year through multiple brokers, we reduce benefits to offset rate increases, and we even light a candle 24 hours before year-end renewal!”

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Texas Association of School Administrators Advocates Alternatives To TRS ActiveCare

September 21st, 2018

TASA advocates for alternatives to TRS-ActiveCare that would provide additional options to districts while sustaining the current system for those districts that remain in the system…………..

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It Depends What The Meaning of The Word “Is” Is

September 21st, 2018

Leaked contract with Express Scripts, the nation’s largest PBM, gets crafty with its definition of “rebate.” The contract carves out so many exceptions to the “rebate” that the PBM itself ends up retaining most of the negotiated discounts for itself.

If PBMs drive up Rx costs, why use them? Why not deal directly with each pharmacy and cut the middle man out? A small Texas county is doing just that with significant savings……………..

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Selecting a Third Party Administrator

September 20th, 2018

By William Rusteberg

With the growing suggestion that the BUCAs are inflexible third party administrators unwilling and unable to administer Reference Based Pricing plans and other strategies in the market today, more brokers are seeking new partnerships with independent third party administrators (TPA). An independent TPA can offer much more than a traditional carrier model.

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Senate Votes 98-2 to Ban Pharmacist Gag Clauses

September 19th, 2018

 

The Senate late Monday passed a bill that would put an end to gag clauses that bar pharmacists from telling consumers when it would cost less to pay cash for a prescription than to shell out the copayment under their health plan………………..

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Xerox, Eastman Kodak And Cost Plus Insurance

September 18th, 2018

trojan

“The challenge facing successful business ventures is to understand the necessity to continuously respond to market forces in a proactive manner since competition will certainly become a factor to consider at some point. To ignore this basic business premise by remaining complacent is business suicide.” – Bill Rusteberg

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Secret Hospital Deals That Squelch Competition

September 18th, 2018

Contracts with insurers allow hospitals to hide prices from consumers, add fees and discourage use of less-expensive rivals………………………. Read the rest of this entry »

My Discount Beats Your Discount!

September 18th, 2018
Plan sponsors are probably the most confused group of people in the history of mankind. Every health insurance salesman that comes in the door says the same thing, “My discounts are the best!”

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Selling Fear & Cost Plus Insurance

September 18th, 2018

The most powerful selling tool is fear. It motivates buyers to act quickly and decisively without basis of reasoned consideration. Depending on the level of fear a seasoned salesman can gin up during his close,  fees to be charged and eagerly paid by the victim are directly and proportionally related. Higher fear levels bring higher fees.

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How Hospital Reimbursement Does and Does Not Work

September 6th, 2018

Hospitals create chargemaster prices by multiplying the cost they pay for a product by 300 to 1200%. Another little hospital secret is what is called an outlier payment…………………….

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Anthem To Offer New Association Health Plan in Las Vegas

September 6th, 2018

The Las Vegas Metro Chamber of Commerce announced Wednesday that it is partnering with Anthem Blue Cross Blue Shield to offer health plans to its members under a new Trump Administration rule that makes it easier for small businesses to collectively purchase insurance…………….

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