admin – Risk Managers

The ACA Was The Greatest Piece Legislation Ever Passed?

“It was corporate statism, painted in the pastel colors of progressive compassion.”

Best Practices for TPA Evaluation, Selection, and Contracting

“A health plan’s fiduciaries are responsible for administering the health plan. Because most employers are not in the business of administering health benefits, they outsource the day-to-day health plan administration to a third-party health plan administrator (TPA). This outsourcing does not mean the employer is off the hook for their fiduciary obligations under ERISA. Even the evaluation and selection of a TPA is itself a fiduciary act, and employers must follow a prudent process.”

How Artificial Intelligence is Reshaping Health Insurance

“There is nothing permanent except change” – Heraclitus

As AI technology continues to evolve, its applications in health insurance will expand further. Insurers that embrace AI-driven solutions will gain a competitive edge…..

Marpai “Takes Decisive Action To Revolutionize Self-Funded Employer Health Plans”

MARPAI ACCELERATES HEALTHCARE TRANSFORMATION WITH EMPARA COLLABORATION, LAUNCHING UNIFIED HEALTH ENGAGEMENT PLATFORM

TAMPA, Fla., March 18, 2025 /PRNewswire/ — Marpai, Inc. (“Marpai” or the “Company”) (OTCQX: MRAI), a technology platform company and a disruptor in the $22 billion Third-Party Administrator (“TPA”) market, is taking decisive action to revolutionize self-funded employer health plans. Today, Marpai announces a strategic collaboration with Empara, a healthcare technology innovator, and an immediate rollout of Empara’s cutting-edge Health Engagement Platform.

70 Best Risk Management Blogs and Websites in 2025

The best Risk Management blogs from thousands of blogs on the web and ranked by relevancy, authority, social media followers & freshness.

“It’s Like Being On Crack!”

“A staggering 85% of people using GLP-1s primarily for weight loss stopped within two years. And almost all regained the weight.”

Oklahoma Insurers Scramble After Drivers Learn About Hidden Rebates

Oklahoma Drivers: You may be eligible to receive a massive discount on your insurance. New rules greatly favor those who drive less than 50 miles/day, and insurers are scrambling as drivers learn about this. Those who live in qualified zip codes can get even larger discounts.

550 Women Could Cost Texas State Health Plan $9,600,000.00

Texas legislators are considering gifting almost $10 million to pay for a new health plan benefit for approximately 550 plan members of the Texas state employee health plan. The “gift” is projected to cost 5% more each year due to medical inflation.

President Donald J. Trump Announces Actions to Make Healthcare Prices Transparent

EMPOWERING PATIENTS THROUGH RADICAL PRICE TRANSPARENCY: Today, President Donald J. Trump signed an Executive Order to empower patients with clear, accurate, and actionable healthcare pricing information.

The Mystery World Of American Prescription Drug Financing

Let’s assume the illustration above is true. What does it tell us about manufacturer average commissions (rebates) imbedded in their wholesale pricing?

Medical Insurance vs Confrontational Medicine & Back To The Future

“For some it’s hard to imagine the future, a future which is unfolding right now before their very own eyes. This future is yesterday in many respects except for one………..it’s better.”

Texas Reporterette Slants Reporting Against Free Market Choice

“How dare politicians take away health care benefits!” says the flower girl at Starbucks on Congress Avenue.

“Nothing of the sort!” says the cowboy stopping by to experience life on the other side. “Texans don’t have to buy the only health insurance they can afford. It’s their choice.”

Inside the Weiderhold v. AssuredPartners Complaint and Assured’s Alleged Motive to be “Opaque as Hell,” with Its handling of Client Rx Rebates

By Craig Gottwals

In this case, Alan Weiderhold alleges that AssuredPartners and its affiliates fraudulently concealed pharmaceutical rebate compensation owed to Plan Sponsors (employers who offer ERISA-regulated self-funded health plans to employees). Wiederhold was an executive at Evolution Healthcare (EVHC), a division of AssuredPartners, and claims he was wrongfully terminated for attempting to comply with legal disclosure obligations under ERISA (Employee Retirement Income Security Act) and the Consolidated Appropriations Act (CAA) of 2021.

A Health Plan Run By Doctors

This model is built around cost savings norms our physician partners have recorded. They are also well supported by independent analyses such as this one by the Society of Actuaries, or this one published in the American Journal of Lifestyle Medicine

Everyone Is Paying For Mary’s Deductible Because Mary Isn’t

Lucky Mary. She has a $1,500 deductible through her employer’s health plan but everyone else is paying for it because she’s not.

Solving High Cost Health Care Takes Unconventional Out-of-The Box Strategies

Solving the high cost of health care takes a team effort employing unconventional means towards a winning end.

Mail Order Specialty Pharmacy Touts Huge Savings

RightRx touts significant savings. How do they do that?

The Rise of Cash Pay Health Plans

In 15 minutes you will know more about Cash Pay Health Plan strategies than most Plan Sponsors.

The Fiduciary Obligation to Avoid 56,000% Markups on Rx

Lessons from the Latest ERISA Fiduciary Suit vs. JPMorgan

By Craig Gottwals

Imagine going to the pharmacy, filling your prescription, and trusting that your employer-sponsored health plan has negotiated a fair price for you. What if, instead, that same prescription was costing you hundreds—or even thousands—of times more than it should?

What Pharmacy Benefit Managers Do, and How They Contribute to Drug Spending

Role of a Pharmacy Benefit Manager in Providing Services and Flow of Funds for Prescription Drugs

* Includes establishing formulary and patient adherence programs and implementing utilization management tools – such as prior authorization, step therapy, and tiering — to steer patients toward certain drugs on formulary.

Data: Adapted from Congressional Budget Office, “Prescription Drug Pricing in the Private Sector” (CBO, Jan. 2007).Source: Kristi Martin, “What Pharmacy Benefit Managers Do, and How They Contribute to Drug Spending” (explainer), Commonwealth Fund, Mar. 17, 2025. https://doi.org/10.26099/fsgq-y980

Health Insurance Is Not Really Insurance Anymore

By Molly Mulebriar

Health insurance in the United States is no longer insurance in the traditional sense. It’s become an entitlement welfare scheme that’s fast becoming a heavily regulated government utility.

Calamity

Want to get into the insurance business? Here’s your chance……….

Medical Cost Comparison Shopping At The Click of A Button

The Power of Artificial Intelligence In Health Care Financing

AI is changing the world as we know it. For us we’re using it to lift the codes and prices from the medical bills and repricing it. This is much cheaper than owning/leasing claim adjudication programs and the human capital needed to operate these organizations (TPAs). AI allows you to take a picture of your bill and be done with it. The same transformation happened with buggy whip makers over 100 years ago. The automobile (ai) replaced how things used to work. That moment is now in the benefits industry. Next year or two it will be a lot smaller, cheaper, and less complicated” – Leon Wisniewski

ChatGPT, Please Provide A Cash Pay Health Plan Proposal

By ChatGPT

A Plan-Sponsored Cash Pay Health Plan is an alternative to traditional insurance that allows an employer to fund healthcare expenses directly, often leveraging cash pay discounts from providers. This approach can reduce costs while offering employees flexible, transparent pricing for medical services.

FDA Sued Over ‘Reckless And Arbitrary’ Semaglutide Decision

Article Referred By Tina Taylor

The Outsourcing Facilities Association (OFA), a Texas-based trade association focused on distributing compounded medications throughout the healthcare industry, has sued the U.S. Food and Drug Administration (FDA) for removing semaglutide from the federal drug shortage list.

Legacy TPAs Face Extinction

“Technology decisions can make or break a TPA’s ability to evolve, remain profitable and provide best-in-class service. But with legacy claims platforms, outdated member portals, and ongoing data issues, many TPAs are stuck or unsure where to focus next.”

The Rise of AI Powered Health Care

“AI is a transformative force reshaping how people engage with their benefits…….we are making benefits easier to use and empowering individuals with our AI-powered digital insurance wallets.”

PatientPAL

Many believe transversing the American health care system requires supportive Motherhood. PatientPAL serves that need………………..

The Rise of Self-Service Health Care

Back in the day …… “A car pulls up and out of the station spring four uniformed attendants who not only fill the tank, but check the tire pressure and oil and wash the car’s windows.“

Revolutionize Your Approach to Cash Pay Health Care Transactions

A Cash Pay Health Plan is easy to implement. You don’t need to pay exorbitant Care Navigation fees anymore when it can be done on a self-service basis with a click of a button.

Give Me Some Sugar!

By ChatGPT

Consuming sugar can have notable effects on both mood and energy levels. While sugar provides a quick source of energy, its impact on the body and mind is complex and can lead to both immediate and long-term consequences.

Plan Sponsors Don’t Need Stop Loss Insurance When They Do This

Nothing is forever. Not even a group health insurance plan. Cost has a limit. Sustainability is a constant.

The Great Statin Argument

“A long habit of not thinking a thing wrong, gives it a superficial appearance of being right, and raises at first a formidable outcry in defense of custom. But the tumult soon subsides. Time makes more converts than reason.” – ANONYMOUS

10 Drugs Poised To Be Best-Sellers In 2026

Article Referred By Jeff Barnhard

Four of the 10 medications Statista anticipates will yield the largest sales in 2026 are GLP-1 medications, according to data shared with Becker’s.

Texas Senate Passes De Facto Mandatory Diabetes & Weight Loss Program

““When I grew up, it was eggs were bad for you and steak was bad for you, right?”

Attention Plan Sponsors: ACA Compliant Health Insurance For Dependents

Employer paid health insurance is a great benefit. The problem is most employers don’t pay for dependent coverage. That’s a problem.

Lawsuit Alleges Insurance Brokerage Hoards Rx Rebates

“EVHC’s business model is based on hoarding rebates from PBMs, the complaint alleges. It states that in 2024, 61% of the company’s revenue came from rebates.”

Dallas-Area Pharmacist Sentenced To Prison In $145 Million Health Care Fraud

Untrained teenagers were mixing prescription creams, which were billed for thousands of dollars.

By Sarah Bahari

A North Texas pharmacist was sentenced to prison for a scheme to defraud the federal government out of millions of dollars for skin creams.

Want To Cut Admin Waste? Cut Out The TPA

“Don’t bother doing something unless you’re radically different from the competition” – Richard Branson

South Texas Politics – A True Story

“You are short sighted. When the new board gets in you will regret this.” – TPA

Diabetes 2 Remission Program

Heuro Health’s Type 2 Diabetes Remission Program For Employers

Rebates Lower Cost

An American industrial complex adopts an innovative method to turbocharge profits for a slew of intermediaries while making consumers believe they are getting the best bang for their buck.

Why Would A Plan Sponsor Not Do This?

Armando Polanco sent this to us today along with a note: “I recently ran the attached report for a group and still waiting to hear from them.”

The Rojas Report

Go HERE to see the first episode of The Rojas Report – Exposing the racket. Breaking down the business of healthcare.

In Rural Texas, a Measles Outbreak Hasn’t Swayed Vaccine Skeptics

She says she is against vaccines in general and scoffs when asked about the Covid-19 vaccine………………..“This is West Texas,” Romano says. “We don’t believe in that.”

Wisniewski Genius At Work

By Leon Wisniewski

I am pleased to tell you that we have successfully built an AI model to extract the procedure codes and pricing information from medical bills.

87% Of Americans Are On Government Funded Health Insurance

Those who argue against a single payer system ignore current realities.

How PBMs Make Money: PBM Practices & Profits

SOURCE: RxSafe

Growing awareness about the problems and pitfalls with pharmacy benefits managers (PBMs) in the US healthcare system has taken hold in recent years. Originally contracted by insurance carriers to negotiate on their behalf with pharmaceutical companies, these “middlemen” have hijacked the prescription drug marketplace to the detriment of pharmacies and patients.

When People Say “Why Is Healthcare So Expensive?” Show Them This Graph

By Chris Barakat – First Primary Care

Just remember. When people ask why is healthcare so expensive? And why are hospitals going out of business? Show them this graph.

Oxbridge Health Disrupts Texas Healthcare Market

Oxbridge Health Disrupts Texas Healthcare Market with Innovative Episode Benefit Plans for Self-funded Employers

MyHealthGuide Source: BusinessWire (full text), 3/5/2025

NORWALK, CT – –Oxbridge Health, an industry leader in episode-based healthcare solutions, announces its entry into the Texas market with Episode Benefit Plans designed to transform how self-funded employers provide healthcare benefits. These plans offer a compelling alternative to traditional health insurance programs, featuring more than 50,000 unique episode care groups statewide with full price transparency and the freedom for members to choose any physician or hospital.

Do Not Eat These

By Mark Hyman, M.D.

DO NOT EAT THESE. Discard immediately if you recognize any of these in yours or a loved one’s kitchen. It’s the easiest act of love you can do for them today.

“Somebody Has To Get The Rebates”

I had an interesting conversation with a PBM industry insider at a recent Happy Hour event in Houston last week. I learned a lot that I probably shouldn’t know.

Gary F. Slavearbejderen Has An Epiphany

Gary F. Slavearbejderen, a group health insurance broker, works hard for his money and takes a lot of abuse from unhappy claimants at the same time. He has to keep up with ongoing federal regulations continuously advising his clients about new developments in a fast moving industry. Gary earns a hard $350,000 a year.

4 ICHRA Trends Health Plans Can’t Afford to Ignore in 2025

The momentum of Individual Coverage Health Reimbursement Arrangements (ICHRAs) continues into 2025.

ICHRA is a modern health benefit solution that enables employers to reimburse employees for their health insurance premiums and other qualified medical expenses. Unlike traditional employer-sponsored health coverage, ICHRA allows businesses to set defined contributions, giving them greater control over costs while ensuring compliance with Minimal Essential Coverage (MEC) requirements.

Barakat’s GLP-1 Weight Management Program

We are expanding our GLP-1 weight management program to employers with over 1,000 EEs.

Wegovy Price Cut For Cash Pay Health Plans

Less than two weeks after Zepbound-maker Eli Lilly reduced the price of the weight-loss drug, competitor Novo Nordisk said Wednesday it would cut the price of its popular weight-loss drug Wegovy for cash-paying customers.

A Common Sense Solution To Public Sector Health Insurance

Curative Insurance Company based in Austin, Texas has a unique health plan offering worth exploring. This compelling 30 minute webinar recording outlines their program.

Are You Getting Stop Loss Credit For Your RBP Plan?

Source: Tokio Marine Stop Loss Group 2024 Annual Market Report

By Jen the Actuary – FSA, CERA – “Renegade Actuary Empath”

Are you getting credit from your stop loss carrier for your RBP contracts? The graph speaks for itself. If you weren’t convinced before you saw the data… here you go.

Aldeen’s Sunday Morning Bathroom Read

Doug AldeenDoug Aldeen – ERISA Healthcare Attorney and General Counsel – Visit my website

Opposition is quickly forming against the Biden administration’s rule to ban medical debt from appearing on consumers’ credit reports, threatening the viability of what could be a popular regulation.

Hospitals Smell Blood

25 health systems file ‘opt-out’ antitrust lawsuit against Blue Cross Blue Shield

Jakob Emerson

A group of 25 health systems encompassing more than 80 hospitals have filed an antitrust lawsuit against the Blue Cross Blue Shield Association and its 33 independent entities, alleging anticompetitive practices that led to suppressed payments to providers.

Medical Expense Cash Card

We are seeing more Cash Pay Health Care Financing schemes every day. This is the latest one we’ve heard about. The mechanics revolve about virtual credit/debit cards. There are all kinds of applications. FSA, HRA, high deductible plans, cash pay centric plans, and more. Let your imagination run wild (How about a high deductible plan that cost plan members nothing until they use it?). – Bill Rusteberg

Who’s The Actuary Who Screwed This Up?

Blue Cross Blue Shield of Michigan posts 2024 operating loss amid rising medical claims

By Candice Williams – The Detroit News

Blue Cross Blue Shield of Michigan reported Monday an operating loss of $1.7 billion in 2024, as the insurer paid $3 billion more for medical and pharmacy claims costs for members than in the previous year. The company saw a loss of $1.02 billion on enterprise revenue of $40.6 billion for the year.

Curative Health Insurance Company’s Financial Strength Rating Affirmed by AM Best for Third Consecutive Year

AUSTIN, Texas–(BUSINESS WIRE)–Curative Insurance Company is proud to announce that AM Best, the global credit rating agency specializing in the insurance industry, has affirmed its A- (Excellent) Financial Strength Rating (FSR) and Long-Term Issuer Credit Rating (Long-Term ICR) of “a-” (Excellent) for the third consecutive year. This affirmation reflects Curative’s continued financial stability, robust risk-adjusted capitalization, and commitment to its innovative employer-based health plan.

ASAS Health Clinics Need Trustworthy Agents On-site

The Valley’s hottest value-care provider, ASAS Health, has partnered with local legend Daniel Wyatt of Covenant Insurance Advisors to help the growing Senior Population of Texas! Now, we need your help to cover each location and get these beneficiaries the help they deserve. To sign up for your on-site location for free, simply join us for a brief info session!

Late Adopters Want Government Mandated Reference Based Pricing

There is a common denominator among us towards solving the high cost of health care to which we can all agree regardless of our political persuasions.

American Greed

By Ramon R. Lizardo, MDRamon R. Lizardo, MD

Let’s be honest, no one should be going bankrupt over a trip to the hospital.

Trump Will Bring America First Drug Prices by Knocking Out the Middlemen, Making Europe Pay Its Fair Share

“We’re going to knock out the middleman. We’re going to get drug costs down at levels that nobody has ever seen before…………….The horrible middleman that makes more money, frankly, than the drug companies, and they don’t do anything except they’re a middleman.”

The 100% Freedom Plan

This health plan is an expense account funded by your employer.

“When you go out of town on company business and have to stay overnight we will pay for your hotel room. The expense account limit is $150 per night so if you decide to stay at the Ritz Gold Star Hotel you will have to pay the difference” explains Sally in accounting.

How To Afford Your Medications

“If health insurance didn’t cover expensive drugs they wouldn’t be expensive” – Molly Mulebriar

Texas Legal

Texas Legal is a statewide, nonprofit legal benefit plan that was founded by the State Bar of Texas and the Texas State Legislature in 1972 as an effort to better meet the legal needs of Texans.

ful.CashPay

Introducing ful.CashPay – The app that helps users learn, shop and save on healthcare

N.C. Teachers, State Employees Voice Frustration Over State Health Plan

“If the state had followed Folwell’s recommendation to adopt Reference Based Pricing a few years back they wouldn’t be facing a rate increase and a +$1 billion health plan deficit next year. Instead, the state changed the logo on their health insurance card.“ – Bill Rusteberg

Texas Reference Based Pricing

We have been managing self-funded Reference Based Pricing plans in Texas for more than two decades, from North Texas to South Texas, From West Texas to East Texas.

Certain regions in Texas provide a better environment than others for Plan Sponsors interested in breaking away from 40+ years of a failed health care delivery system.

John and Anne Darwin – The Case of The Canoe Conman

One of the most infamous cases of life insurance frauds is that of Brit couple John and Anne Darwin, whose notoriety has inspired several documentaries. Drowning in debt, the couple realized that their obligations would be wiped out if John faked his own death. Anne helped her husband in doing so in 2002, when John reportedly disappeared in a canoeing accident.