Search Results for: Hospital charge master

“INETICO has put together a complete and effective option to the traditional PPO model……………..” Editor’s Note: Cost Plus insurance, also known as Reference Based Pricing, is becoming a growing market phenomenon. In Texas, Cost Plus Insurance (www.costplusinsurance.com ) made a debut about 6 years ago.  A handful of employers who had the intestinal fortitude to step away from … Continue reading Cost Plus / Medicare Benchmarking Continues To Gain Market Acceptance – Are PPO’s Facing Extinction?

This is your plan. Your costs increase every year. Ours don’t. That’s curious isn’t it?

By Marshall Allen Laurie Powsner had recently left her full time gig as a social worker, so this year she and her husband got their insurance coverage on the individual market. 

By Doug Aldeen In August of 2023, Advent Health fled a lawsuit alleging that MultiPlan’s business model of contracting with fellow payers and aggressively repricing out-of-network service payments is anticompetitive under Section 1 of the Sherman Act.

For decades, hospitals have insisted that they charge the privately insured more to offset losses from Medicare patients. A health care regulator blows the whistle on that myth.

Back in 2007 nay sayers predicted Reference Based Pricing would never work. BUCA reps and their hospital partners circled the wagons with dire warnings to plan sponsors with the threat plan members would not be able to access care.

Many independent fee based insurance consultants are sucked into the PPO “discount” vortex……………..

The Weslaco ISD vs Aetna lawsuit and hundreds like it have exposed certain practices that drive up costs which most plan sponsors are not aware of.

“Employers who are leveraging these cash pay strategies are saving so much money that they can offer healthcare benefits at no cost to the employee, no employee premiums and no out-of-pocket expenses like copays and deductibles.

Why would any plan sponsor that’s able to pay cash at the point of service reimburse a hospital more than their discounted cash price? The time value of money in a typical claim cycle averages 90 days X cost of money. What is 90 days worth in the value of services received in today’s dollars? … Continue reading Time Value of Money In Healthcare

This graph represents all you need to know about what’s driving healthcare costs in this country.

By Bill Rusteberg White Flag plan sponsors are those employers who cower to the Great American Health Care Industrial complex, willingly prostrating themselves to continued abuse at the hands of hospital administrators, insurance companies and a host of third party intermediaries.

Prediction that COVID Has “Small Impact” in Health Insurance Carriers Becomes Reality

The cost of money transfer under health insurance plans is +600% more than under a credit card transaction. Cash pay centric health plans cuts out all that wasted money……….

A friend,  fellow health care disruptor and collaborator shared his personal experience navigating the American Health Care System in an email sent us this afternoon.

A recent Supreme Court case in Texas involving a hospital lien held that contract payments involving Medicare multipliers and other accepted payments could be evidence of reasonable, fair market value.

Creates a complex arbitration process between insurers/ self-insured plans and medical providers…………Arbiters are prohibited from taking into account the provider’s “list price” billed charges……………..

Specialty drug approvals, emerging gene therapies, less relevant PPO discounts, double digit higher charge master rates in 2021, more aggressive billing practices and COBRA provisions related to the pandemic will impact rates well into the coming year.

“Hospitals claim that hiding prices allows them to offer large discounts to insurance companies.” Then why do Hospitals Dismiss Significance Of Chargemaster Prices?

By Bill Rusteberg Health care costs have remained essentially static over the past 15-20 years yet health insurance costs have skyrocketed. Here’s why……………

Health Insurance 101 Chapter 1 Correlation Between Provider Reimbursement & Rate Setting Chapter 1 Takeaway: GREEN IS GOOD, RED IS BAD By Molly Mulebriar Provider reimbursement difference between a traditional Managed Care plan (PPO) and a Reference Based Pricing plan is illustrated in the graph above.

A step by step guide to earning your first billion in American health care…………….

There is no doubt catastrophic claims are on the rise. Turbo-charged hospital bills reach the ever present stop loss outlier provision (common to most managed care contracts) faster than a melting Raspa in deep South Texas on a hot day in August.

“The patient spent 1 hour in the OR.  I kid you not, the facility billed $153,887……….”

We have reached a tipping point in the battle against high cost health care. Employers have run out of money to pay for it. Employees can’t afford to use their health insurance anymore. Meanwhile hospitals continue to game the system with egregious charge-master pricing and their disco-discount game with their carrier partners. They have effectively … Continue reading The Mother of All Health Care Battles Looms

 An idea with bi-partisan support?

The way out of this mess is for Americans to remove themselves from the health insurance market altogether—or to participate in other forms of health insurance such as health sharing ministries and short-term insurance plans. Individuals can actually pay a doctor, hospital, or outpatient center for a service performed without filing claims or getting pre-approval … Continue reading Gateway to Health Care: The Clerk In The Cubicle

Transparency in health care pricing doesn’t make a whole lot of sense when it’s other people’s money paying for all of this. Who cares what the cost is when all you have to pay is a small co-pay, or some sort of deductible. Then, when you enter that Magical Kingdom called Maximum-Out-Of-Pocket Limit you tend … Continue reading Trump Ready To Force Transparency In Healthcare Pricing With An Executive Order

A long time friend who has spent almost all of his working life in the pubic purchasing arena in Texas has a perspective that many of us in the insurance community have failed to acknowledge. 

In the article by Marshall Allen that follows patient questions why Aetna paid  a grossly inflated rate of more than 300% of Medicare for his in-network claim. Well, that’s not the way Aetna or any other managed care company wants you to look at it. Instead they want you to focus on “discounts.” Managed care … Continue reading Insurer Paid +300% of Medicare But The Discount Was Really Good

Oh, this makes sense! Everyone knows what 1100000003 is. Last time I had a 1100000003 was last year and my insurance paid only $1,654 for almost a 50% discount. Oh-My-Gosh, 1100000027 looks really competitive………! I’m going to Christus Health next time!

Commission driven broker / consultants push certain products over others. Here’s an example…….

The American health care revolution is in full swing and growing………………….

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.

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.

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………………

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

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.

Lawsuit highlights one risk associated with reference-based pricing models: balance billing…..

Imagine a banana in a supermarket.  It costs $1 for those paying with Visa, $3 for those paying with MasterCard, and $32 for those paying with cash.  You can’t sign up for Visa until you’re 65, and you can only get a MasterCard if you have a nice employer or a decent income.  Worse, customers … Continue reading How Much Did You Pay For Your Banana?

On June 25, the US Supreme Court issued a 5–4 opinion in a case that may have significant implications for health care……………….The case of the two-sided transaction………………

$25,308 Emergency Room Visit Hospital sued for egregious pricing…………hospital responds by waiving all charges………Judge dismisses lawsuit…………Plaintiff appeals and wants to continue the lawsuit………….Appellate court agrees……..lawsuit continues……………..What is reasonable value of the treatment? Stay tuned……..

Montana’s high-stakes game of chicken designed to change how the state did business with its 60 hospitals, which accounted for 43 percent of employee health care costs, turning the normal purchasing process on its head……………………..

  An idea with bi-partisan support?

“Reference Based Reimbursement, while not perfect, provides a clear and distinct effort to bring attention to the actual cost of healthcare goods and services.” – Scott Haas

The health care industry is closely watching a recent decision by the Texas Supreme Court that some say could have broader implications on how hospitals and health insurers negotiate their rates………………..

In Martinsville, Virginia, there is a reference-based pricing lawsuit pending that industry insiders are watching closely, because it could set a precedent for these types of lawsuits moving forward. In this case, a Virginia hospital has been pursuing an $84,000 balance bill from a former patient for nearly four years and through two separate courts……………………

The Weslaco ISD lawsuit against Aetna is a fascinating read. The pleadings provide clues for those who are curious about various revenue streams found (or not found) within some administrative contracts for third party administration of group medical plans.

  An idea with bi-partisan support?

The Weslaco ISD lawsuit against Aetna is a fascinating read. The pleadings provide clues for those who are curious about various revenue streams found (or not found) within some administrative contracts for third party administration of group medical plans.

Mike Dendy Eliminating the PPO domination of healthcare financing will represent a paradigm shift but one that is long overdue.

Amazing what people will do when they get told what their real costs are…………….

Many independent fee based insurance consultants are sucked into the PPO “discount” vortex…………….. “The carriers are very good at playing this game and my belief is that most consultants don’t get it or pretend not to get it, thus doing a great dis-service to their client.”   – PHO Sales Representative

Is the fox is watching the henhouse? The abuses that can and do exist under this model are egregious…….

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

It’s been eight years since I wrote Health Care Strategies for Texas Political Subdivisions: costplusinsurance.com/articles/Health%20Care%20Strategies%20for%20Texas%20Political%20Subdivisions.pdf Since then there have been early adopters who have blazed the trail for others to follow. But most Texas political subdivisions still have their heads in the sand.

Our website (www.mollymulebriar.org) gets emails from time to time through our Tip Line exposing industry secrets……

The game is over. Plan sponsors are becoming more educated. The secret ingredients of managed care contracts are now known to many. And they are mad as hell and not going to take it anymore.

You may have asked yourself why health prices rise inexorably. Are escalator clauses, the automatic price increases common to many managed care contracts, the driving force behind trend factors?

“Some business is being diverted away from hospitals and toward retail clinics, standalone surgical centers and urgent care facilities that advertise their prices and services……….…’

Wikileaks today has released Part One of Mulebriar’s exclusive interview with Julian Assange. The interview was held at the Ecuador embassy in London on Monday.

Revenue has  increased 4.2 percent year over year, to $10.3 billion in the third quarter of 2016. Could the ever present annual escalator clause found in managed care contracts be driving revenue increases?

 John Farnsley “We learn from history that we do not learn from history” – George Hegel

“Understanding the cost of health care is directly related to what we agree to pay, more and more employers are questioning managed care contracts upon which their health care costs are based. Many are discovering the truth for the first time.”

Hospitals have charge master pricing. Pharmaceutical manufacturers have AWP pricing. Consumers pay neither. These are simply made up numbers from which sellers “discount” their wares/services.

Plan sponsors want to know which PPO network has the best and lowest costs. They hire consultants to find out.

Many Texas employers have been using reference based pricing strategies since 2007. These early adopters have enjoyed great success in containing medical costs. All have succeeded in beating medical trend, maintaining static costs while improving benefits.   Markets sometimes take time to adapt, as the status quo is always in the best interests of vested … Continue reading The Next Innovation In Controlling Healthcare Costs

By Molly Mulebriar When a hospital refuses to accept a patient because their health insurance plan limits allowed charges to 120% of Medicare reimbursement rates, and instead offers to discount their charges by 15%, one wonders how much more will the patient be asked to pay. Of note is the hospital routinely accepts 100% of … Continue reading No, We Won’t Treat You Unless You Pay More!

“It’s possible to deliver ”twice the healthcare, at half the price and 10 times the delight.” It might sound too good to be true but employers large and small are doing it and spending 20-55% less per capita on health benefits with packages that are better than what 99% of the workforce gets. It simply … Continue reading Healthcare Industry – Redistribution of Profits From Employers

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 … Continue reading The OPEC OF Healthcare

“As someone that has made a career trying to help healthcare providers and health plans get on the same page as it relates to cost-containment initiatives, I have compiled my personal top ten lessons about RBP from 2015.” – Jason C. Davis

  An idea with bi-partisan support? If the federal government would rent their Medicare network and charge what the private market charges for PPO access, the government would rake in millions, if not billions of dollars in access fees. This would generate enough money to buy health insurance for those that don’t need it.

“Fed up with soaring costs, Dallas and 30 other North Texas municipalities are asking hospitals to submit bids indexed to federally controlled Medicare prices to cover the cost of care for city employees”

 David Belk, M.D. In my video I discuss the three reasons “insurance companies want hospitals and other health care workers to over-bill by so much.” I bet these reasons will surprise you (especially the last one).

By Molly Mulebriar My Chief of Staff was breathlessly awaiting my return from lunch today. “Guess what, I found a heretofore unheard of PPO network that has great discounts! We should contact them!” “Show me the evidence” I demanded.