admin – Risk Managers

Remember Back In The Day When PBMs Didn’t Exist?

By Bill Rusteberg

What’s the price we pay for free-credit drug money?

ORIA: Free AI Powered Hospital Price Check

Oria enables price discovery for hospital services with an AI-powered interface that allows anyone to ask questions and quickly discover insights from hospital price transparency files.

J Patrick Rooney – Godfather of Reference Based Pricing

J Patrick Rooney is considered by many to be the Father of Margin Based Pricing better known these days as Reference Based Pricing. Many believe his conclusion of what the “sweet spot” reference point should be still holds true today.

Avym Plays Key Role In Historic $100,000,000 Settlement

Horizon Agrees to Settle False Claims Act Case for $100 Million

Through rigorous analysis and deep industry insight, AVYM principals Mark Flores and Vince Flores assisted state officials in identifying systemic misconduct by Horizon BCBS NJ. This collaboration helped secure a historic settlement and protect public plan assets from misuse.

Is Your Health Insurance Better Today Than It Was 15 Years Ago?

Is Your Health Insurance Better Today Than It Was 15 Years Ago? ……Really? Why Not?……… This 8 minute video offers one view that’s hard to discount……………

Sealed Legal Pleadings Plague Health Care Litigation

“Since when do billion-dollar vendors get to file an appeal in a public court of law – of a public contract – funded with public dollars, affecting public employees – behind closed doors?”

California Passes PBM Reform

By Ann Lewandowski

BOOM… California, the biggest market in the U.S., just passed PBM reform. And sizzle, this is hot.

Here’s Another Health Plan You Didn’t Know Existed (Until Now)

Revolutionizing health insurance with transparent pricing and actionable insights.

GLP‑1 Announcement May Affect Prices for Group Health Plans

The administration, together with pharmaceutical manufacturers Eli Lilly and Novo Nordisk, announced an agreement to lower prices and expand access to glucagon-like peptide-1 receptor agonists (GLP-1s) for weight loss for those in the Medicare Part D and Medicaid programs as well as direct-to-consumer (DTC) purchasing.

24,000,000 Americans Were Gifted 7% of GDP Equaling $1,800,000,000 In 2023

Monies forcibly taken from working Americans and gifted to health insurance companies insuring roughly 24 million people who purchased plans under the Affordable Care Act ACA cost an estimated $1.8T in 2023, roughly 7% of the US gross domestic product.

Healthcare Customer Service is Terrible… Why?

According to Forrester Research, Health Insurance Customer Service is Ranked 15th Out of 19 Industries.

World’s First Transatlantic Surgery

Imagine you need surgery and you want the best surgeon on the planet. You check in to your local 5 bed community hospital on the south side of the tracks where you seldom venture. After you show proof of financial responsibility and sign your life away you are wheeled into the 240 square foot operating room. You look around. “Where’s the surgeon?” you ask. “Ah, he’s in Rio enjoying a leisure day by his pool. But don’t worry, he’ll be performing the procedure remotely” purrs the reassuring PA.

Corporal Jack Meyers

In 1945, the 692nd crossed the Rhine River and advanced across Germany, arriving in Munich by April. Cpl. Myers earned a Bronze Star. See General Orders #172 – Wilber Meyers pg. 5, 27 September 1945.

Veterans Day 2025

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

The battalion began the battle of Hatten with 33 officers and 748 en- listed men. Fifty-two hours later it had an effective strength of 11 officers and 253 enlisted men. All others were either killed, wounded or missing in action.

Billed Charges Disco Magic

By Bill Rusteberg

Billed charges are manufactured numbers having nothing to do with cost or value. It’s simply a starting point designed to create the illusion of value to the benefit of hordes of middlemen feeding off one fifth of the American economy.

Trump Calls For Obamacare Subsidies To Be Sent To Consumers

Impatient ACA plan member supports Trump’s idea

Story by David Nather

President Trump said Saturday that the money that’s being spent on Affordable Care Act subsidies now should be sent directly to consumers — a position that’s likely to complicate the government shutdown deadlock even more.

93% Get Annual Rate Increases, 7% Don’t

By Bill Rusteberg

According to the Bureau of Labor Statistics, in 2023 93% of private-industry workers participating in medical care plans had a plan network. That means 7% don’t.

The Evil Genius of PBMs

“To every broker and consultant who ignored our words, I wonder if you have a conflict of interest? I wonder how many ways you are paid on products, commissions, and overrides by the bad actor in question?”

President Donald J. Trump Announces Major Developments in Bringing Most-Favored-Nation Pricing to American Patients

Slated for 2026, President Trump’s direct-to-consumer TrumpRx website will offer obesity drugs to Americans for as low as $150 for a month’s supply.

Our plans are the best thing since Texas BBQ.

TotalCare plans come with four $0 visits each to different doctors every year to make it easier to get care without worrying about costs.

TPA’s Invited To Participate In Lucrative 12% Charge Master Fee

“Believe it or not there are still Reference Based Pricing firms out there charging fees based on a percentage of billed charges. You would think after all these years plan sponsors would wise up.” Molly Mulebriar

CMS Fee Schedule Updates! And What To Do About It

While you were trick or treating, CMS released its CY 2026 Physician Fee Schedule Final rule. Here’s the link.

60 Best Risk Management Blogs and Websites in 2025

The 60 best risk management blogs and websites in 2025 from thousands of blogs on the web and ranked by relevancy, authority, social media followers & freshness.

Why Blues and Non-Blues Consolidation in the Next 12–36 Months Should Not Surprise Anyone

My Prediction: Consolidation whispers (and not-so-whispers) are about to turn into headlines. Within 12–36 months, expect merger announcements across both Blues and non-Blues.

TrumpRx To Lower Ozempic Price To $149?

If agreements are finalized, President Trump is expected to announce them Thursday morning at the White House, alongside pharmaceutical executives, the people said.

Kingsville ISD Trustees Discuss Patient Dumping Scheme

“We’re pretty excited about it” said Mr. Esquivel, the district’s health insurance broker.

Affordable Care Act “Very Good Value for People In Texas”

by: Adam Schwager – Oct 31, 2025

AUSTIN (Nexstar) — For the nearly 4 million Texans who currently use the Affordable Care Act (ACA) marketplace to get their insurance, Saturday is the time to start looking at renewals. Open enrollment starts then, and in order to have health insurance starting on Jan. 1, current enrollees must select their 2026 plan by Dec. 15. The final deadline is Jan. 15 to get insurance starting on Feb. 1.

Palace Coup – ABC Fence Company Does The Unthinkable

Employees revolt against status quo health care financing in the spirit of “No taxation without representation……….”

Aegis 2025 Medical Stop Loss Premium Survey

Key Survey Findings – 2025

Stop loss premiums vary widely due to deductible size. However, when normalized by contract (e.g. Paid, 12/12), an average cost is determined across the range of deductibles.

Zebound For $179 1st Month, $299 Thereafter

The MEDVi Semaglutide program starts at $179 for your first month with no contract. This cost covers your physician review, full personalized plan, 1:1 guidance, metabolic report, and the cost of the prescription medication shipped right to your door.

The Math Just Doesn’t Add Up

GLP-1 drugs are bankrupting self-funded health plans. We know because we’ve seen it. And it’s ugly, real ugly.

You Don’t Need A Living, Breathing Broker Anymore When Shopping Insurance

Remember back in the old days when you used a local travel agent and now you don’t. Remember sitting down with a living, breathing insurance agent to buy a policy? You may not remember now but you will sooner or later…………..

Curative Blitzkreig Captures City of Pharr

Curative Insurance Company, lead by Generalissimo Juanito Bock, conquers yet another city in the Lower Rio Grande Valley.

Tom Slack

By Bill Rusteberg

Tom was an unusual character, a master salesman and world class communicator. His out-of-the-box antics were impossible to duplicate without severe consequences to anyone else who tried. He was smart, a rising star destined, as was the common belief, to be President of the company one day.

Level-Funded Health Plans Explained

Level-Funding is a hybrid employee health plan between a self-funded plan and a fully-insured plan.

NEW! Online Dental Benefits

Frustrated Reformist Says Money Always Wins – Politics Always Realign

By Chris Deacon

You can spend years trying to do the right thing. Make sacrifices. Tell the truth. Stay the course. Trust the wheels of justice. And still find yourself wondering if any of it mattered.

ACA – A Freeloader’s Paradise

A hardworking professional paying $3,800 pre-tax per month gets the same (or worse) coverage as someone with no income, who qualifies for free, taxpayer-funded insurance………….Encouraging freeloading isn’t social justice — it’s corrosion. It hollows out ambition, punishes effort, and breeds dependency disguised as equity.

Cash Pay Health Plan Overdraft Protection

A self-funded cash pay health plan can and should be funded through a Health Reimbursement Arrangement (HRA). But how does a plan sponsor protect against overdrafts?

Dr. Oz Reveals Plan To Replace Obamacare

Dr. Mehmet Oz joins ‘Mornings with Maria’ to discuss the impact of the government shutdown on Medicare and Medicaid, warning that fraud, waste and political gridlock threaten vital healthcare programs for millions of Americans.

The Employer Health Insurance Reality Check (October 2025) — and Why ICHRA Is Winning

Brad O’Neill is the Founder and Principal Consultant of The ICHRA Shop, a national advisory firm transforming how employers design and deliver health and lifestyle benefits through individual coverage and defined-contribution strategies.

If PBMs Promise 100% Return of Rebates, Why Have Them?

By Bill Rusteberg

We’ve all heard it. “We pass 100% of all rebates on to you” says your favorite PBM.

Gag Clause Attestation Deadline Fast Approaching

October 23, 2025 – By: HUB’s EB Compliance Team

As 2025 comes to an end, plan sponsors of ERISA, church and governmental plans should submit their Gag Clause Prohibition Attestation (“Gag Clause Attestation”) to the Centers for Medicare and Medicaid Services (CMS) no later than December 31, 2025.

RosettaFest 2026: Amplifying Our Voice

Communities leading healthcare transformation from the ground up.

RosettaFest has become the platform where communities take charge of their healthcare destiny. Over 1,000 changemakers gather here to share authentic stories of transformation and amplify the voices of people building healthcare that serves their neighbors first.

These are community advocates, clinical pioneers, benefits champions, and local leaders who discovered their collective voice creates more change than any corporate boardroom ever could.

What Took You So Long To Figure This Out?

99.99% of plan sponsors are slow. Real slow. So slow it makes a melting glacier look faster than a speeding bullet. According to the article below employers are beginning to adopt direct contracting agreements with community health care providers to save money and to improve access to quality care. Plan sponsors we worked with have been doing that for past two decades with good success.

How To Achieve Razor Thin Hospital Margins Without Even Trying

Three Problematic Hospital Myths

“The reality is you can have razor-thin hospital margins if you are good at just spending all the money that is given to you.”

A New Era of True Self-Insurance for Employers with 100+ Employees

This model turns the employer into the master architect of a benefits supply chain — leveraging individual market carriers as infrastructure, not vendors.

Stephan A. Smith Says Kyrie Irving Was Right

ESPN host Stephen A Smith just admitted that NBA star Kyrie Irving was right about not trusting the vaccine.

Awesome Exit Strategy For Burned Out Health Insurance Brokers

Attention burned out health insurance brokers – here’s your exit strategy……..All you need is $15,000 to $25,000 and a P&C license (easy peasy) to start…………..

A New Texas Health Insurance Company You’ve Never Heard Of

New doctor owned and managed Austin based insurance company offers both individual and group medical insurance.

Health Care Coverage That Makes More Sense Than The Law Allows

“Traditional health plans are bloated with layers of middlemen, delays, hidden fees, and unnecessary complexity. That’s why we built MedSave — a transparent, cash-based health plan that finally puts control back in your hands” – Bill Rusteberg

Houston Doctor (UNJUSTLY) Punished for Ivermectin Treatment

It’s good for horses but not good for Texas humans? How weird!

Fat American Airlines Crew Members Are Pissed

Flight attendantS at American Airlines (AA) are pissed. The mean and evil airline announced that it will no longer cover GLP-1 medications for weight management for crew members.

Only 37% of Employees Want To Talk To A Real Person About Benefits

63% don’t want to talk with a salesman………………90% say online benefits are very or extremely important……..Almost 9 in 10 Generation Z and millennial employees said online benefits administration is very or extremely important, according to a survey.

How Eli Lilly Became The New King Of The Anti-Obesity Drug Market

By Tina Reed

Eli Lilly is poised to leapfrog Novo Nordisk and become the dominant player in an anti-obesity drug market that could reach $150 billion by the end of the decade.

Tackle Healthcare Costs With TempoPay

Unexpected bills and out-of-pocket expenses can be overwhelming and keep people from getting care when it’s needed most. Let’s change that.

County Switches From Group Health Plan to ICHRA

The switch will allow for the 265 people currently employed by the county to be able to have access to over 30 different individualized plans that can be tailored to an individual’s living circumstance.

Hospitals Hate Revenue Constraining Cost Containment

“Partners in Affordability Become Plaintiffs In Court”

By Chris Deacon

It should surprise no one that the California Hospital Association has sued the state over the Office of Health Care Affordability’s new cost growth caps.

WinCorp Marketing – Insurance Wholesaler

After working as an agent in the field and on the marketing side of the insurance world for many years, Doug J. West, founder and President, saw a need for something different.

“Our District Is In Trouble!”

By Molly Mulebriar

With help from their insurance consultant the Brownsville Independent School District, the largest employer south of San Antonio, has successfully managed to achieve a $7,000,000 health plan deficit without even trying.

Enshittification

Enshittification: This process, which Doctorow deemed 2023’s word of the year, follows a predictable pattern: corporate entities acquire successful services, then systematically degrade them to extract maximum profit.” Dave Chase

If Hospitals Lose Money on Medicare Why Do They Take It?

“Unless hospitals are committing fraud in their reporting to Medicare, their rates cover their costs and profit. To then complain that getting paid more than double that is a “hardship” is laughable” -Dave Chase

MARPAI RECOGNIZED AS 2025 TOP THIRD PARTY ADMINISTRATOR

SOURCE: PR Newswire – Tue, October 14, 2025 at 3:03 PM CDT 5 min read

Recognition Highlights Company’s Stellar Reputation and Technology-Driven Approach to Smarter Healthcare and Real Savings

Blue Cross Comes Swinging Back With A Sweeping Counter Attack

“If we overpaid or skimmed, it’s your fault for not catching us.”

How Obamacare Set In Motion Today’s Premium Crisis

BySally Pipes – Contributor

Democrats are panicking about a looming 75% average increase in the out-of-pocket cost of insurance premiums next year for the roughly 6% of the population that shops for coverage on Obamacare’s exchanges. Their panic led them to shut down the government at the end of September.

Marketer Makes Pitch For 2026 Government Marketplace Open Enrollment

The government ACA Marketplace Open Enrollment period is fast approaching and we already see marketing activity begin like this one.

The purveyor of this advertisement must know something we don’t know.

This marketer is assuming the ACA subsidies (welfare payments) will continue and many applicants will receive free health insurance.

We think so too. Taking away free health insurance from millions of people is political suicide.

Mike Keogh

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

By Bill Rusteberg

Mike Keogh was an extraordinary man. A former Blue Cross salesman in the 1950’s, he later built an independent brokerage in San Antonio with great success. I met Mike in the early 80’s and did quite a bit of business with him.

Marsh Unit Sues Rival Agency After ‘Retired’ Broker Joins

Proof that personal relationships are worth more than company branding…….

The Future of Employer Sponsored Benefits

By Bill Rusteberg

We are entering a different time now. It’s not the same as it was just a few short years ago. Employer Sponsored Benefits will give way to Employer Sponsored Stolen Money.

Amazon To Start Offering Prescription Drugs Through Vending Machines

Amazon Pharmacy Kiosks will carry hundreds of commonly prescribed medications such as antibiotics and blood pressure treatments on a seasonal basis

Stop Chasing Discounts

By Julie Wasserman

Stop shopping discounts. Using a claims’ repricing to find an extra few discount points is not strategic, nor is it consultative. A monkey could throw some numbers on a spreadsheet and call it a day.

Carrier discounts are worthless because the discount itself is based on a completely ridiculous number. Hospitals are charging up to 800% over actual costs. (See below for the Top 25 states*) These figures are based on self-reported data, but it’s so obnoxious it almost seems like I made it up.