EMPLOYER GUARD DOG vs CARRIER LAP DOG?

The BUCAs and their brokers won’t tell you about it because it goes against their business model…….

Insurance company shows bogus discount designed to convince consumer their worth (Thank God I had insurance!). Consumer on the hook for the balance, or +$2,000 (Not bad, I could have been on the hook for +$17,000 without insurance!). Cash price is less than $500 (that’s still too much). This kind of bullshit happens every day………………..

By Bill Rusteberg

Plan sponsors new to self-funding invariably ask “How much do I need to set aside for reserves upfront?” The answer is you don’t. Instead you fund 18% of your expected liability, or 1/12 x 2.25 during the first three months of the new plan.

Independent TPA’s, especially with those with out-of-the-box solutions, are second class citizens scrabbling for business in the insurance brokerage community.……..

Hospital price caps gain traction among state governments as a means to lower health care costs………..

SOURCE: Doug Aldeen, Attorney At Law & Godfather of IRC 501r

The Texas Hospital District statute takes charity care one step further: Texas places the burden ON THE FACILITY to establish the ability of the patient to pay at cost.

By Deb Ault

Patient calls the AIMM nurse because she is in the ER.  This doesn’t require precertification but the nurse asks a few questions about what landed her in the ER.  She begins to tell the nurse that they want to admit her, but they don’t have any beds.  They told her that she would have to be admitted in order to get an MRI because they “don’t do those for ER visits”. They told her that if they can’t find a bed for her, they would have to transport her to a different hospital via ambulance to have the MRI done and be admitted. 

Recognizing that local governments engage in a wide array of cooperative efforts with each other in the purchase of goods and services as a method to reduce duplication, offer economies of scale, and generally improve governmental efficiency, RISKMANGERS Agency was created by participating local governments sharing these common goals.

RISKMANAGERS Agency is an administrative agency created by the participating local government Members as authorized by Section 791.013 of the Texas Government Code to supervise the performance of an interlocal contract.

“The market is working, and we should let it continue……………………….”

Imagine a red hot market demand for weight reducing drugs under patent costing north of $12,000 per year with a lifetime dependency, prescribed by physicians and paid for with other people’s money.

Medical Stop Loss Captives are a growing market phenomenon catching the attention of small to medium size plan sponsors. A Captive can be structured to meet the specific needs and goals of like minded member employers.

CLEVELAND — aequum LLC, acting on behalf of 400 self-insured health plans and their participants, announces a noteworthy two-year milestone of successfully resolving over 10,000 claims for more than 5,000 member patients, saving over $37 million of disputed charges and earning recognition throughout the self-insured community.

SOURCE: Survey: 62% of Millennials Would Put Pet’s Health Before Their Own (prnewswire.com)

Seventy nine percent of millennials say they ask “Dr. Google” about an ailment before making an appointment to see an actual doctor. Almost half (45%) are more likely to try telemedicine before visiting a doctor’s office.

Now that you know, and they know, you’re screwing your employees it’s time to understand that, whether you like it or not, you’re in the health insurance business. Poor oversight and bad decisions will not stand anymore……………….

You would think a hospital would give a better price for cash than they would for insurance companies. No claims to file, no chasing patient share, immediate cash payment, no precertification bullshit, no concurrent care review protocols to mess with, no prolonged verification of benefits phone calls, etc.

Insurance companies provide the illusion that by using their in-network providers you will save money.,,,,,,,,,,,,,,,,,,,,,,,,,

58% of Americans earning less than 400% of the Federal Poverty Level qualify for free health care. Most plan sponsors have failed to recognize the impact this would have on their second most expensive business expense after salaries if they would simply transfer risk through IRC 501r hospital financial assistance policies.

100% bipartisan support punishes hospitals in a meaningful way who don’t publish their prices for all to see…………

Does your TPA ASO Agreement include limited audit rights? If so your plan may be non-compliant with the new No Gag Rule for group health plans.

A $900 per month drug with a $25 co-pay seems like a great buy for plan members fighting obesity. But it only takes a few plan members to drive up a plan’s drug spend to budget busting levels………..

The 단고기료리전문식당 is part of leader Kim’s efforts to improve people’s diets………………

By Marshall Allen

I recently reviewed the bills of a woman whose insurance plan had negotiated a price for her and her health plan to pay $5,805 for an emergency room visit.

Ava Ortiz, age 6, gave an impressive performance this evening at the Houston Rodeo’s Mutton Bustin event.

“Some protest or grumbling with an acceptance does not invalidate the agreement…….”

All industries compete on price and efficiency, but the healthcare industry exists to maximize billings and revenue.

“Sadly, healthcare in the U.S. has become dominated by third-party payers. This means that the government – through public insurance programs like Medicaid and Medicare – along with employers and insurance companies, pay most of the bills to hospitals and other healthcare providers. They pass this cost along to patients and taxpayers, of course, through higher insurance premiums and higher taxes, but this means there’s no downward pressure on price, and little leverage (absent government action) for price transparency”

Removing the third person from the room is every physician’s dream. For DPC doctors the dream has become true.

In 2012, Insys hired a new sales executive: Sunrise Lee, a Florida escort service manager and former strip club dancer with no academic degree, according to Guzman’s complaint. Burlakoff allegedly defended the decision, claiming, “Doctors really enjoyed spending time with her and found Sunrise to be a great listener.” He added, “She’s more of a closer.”

One critical Benchmark for a healthplan is Medical Expense Per Employee Per Year (PEPY). Our #FairCostHealthPlan is $4,428 PEPY while the national average is $12,125 (Truven Medstat) – 64% below the nat’l average.

“Why should a plan sponsor negotiate a hospital contract when plan members do that already?” Bill Rusteberg

Eli Lilly is slashing prices on its most-prescribed insulins and capping out-of-pocket costs for patients amid pressure from consumers and the Biden administration. After years of price hikes on insulin, Lilly on Wednesday said people with diabetes would see 70% reductions on its most common versions.

National Care Dental offers PPO plans underwritten by Met Life and Nationwide under one contract.  You will have a unique enrollment portal and network for each carrier, however a shared back office to view your book of business and commissions.  Great brand names to promote!

Employees Earn $4,128 Pay Raise Plus Free or Almost Free Health Insurance……..

Mueller Manufacturing Company decided there was a better way to provide their 300 employees with free or almost free health insurance while gifting them a raise at the same time.

Your groups could be saving 43% on health benefits by utilizing an ICHRA.

Holy Smoke! I’m in the wrong business………………..

Blue Cross ASO Agreement with a Florida school district is posted on the world wide web. Now that it’s posted here let’s see how long it stays in the public domain.

To estrange themselves further from their calling, doctors bow as never before to the state and the corporation.

An ICHRA is by definition a group health plan providing a superior method of health care finance for plan sponsors………. for a lot of reasons.

Within 24 hours of posting a link to a copy of Texas A&M’s BCBS ASO Agreement it has been removed from the internet. The Cone of Silence continues………………..

Suit Against Anthem Exposes Conflict Over Health Claims Data

Article Referred By C. Smith, M.D.

An employee health plan sues its health insurance administrator for refusing to turn over claims data that would allow the employer to verify the accuracy of charges against its self-funded health insurance plan. Medical supply vendor Owens & Minor says Anthem Blue Cross and Blue Shield has refused to provide it with claims data since 2021 as required by federal law. Anthem says its claims data involves proprietary arrangements that it doesn’t want to make public. Several similar lawsuits have been settled out of court, with details hidden behind non-disclosure agreements.

The Texas Hospital Association has concerns, including that providing itemized invoices for every patient’s bill would be costly and time-consuming. 

Doug Aldeen• ERISA Healthcare Attorney and General Counsel

The state of Connecticut plans to erase $2 billion in medical debt for its residents.
Caveat Emptor and Key Inquiries: 1) Determine the original price of the medical services and 2) How many individuals were otherwise eligible for financial assistance? Perhaps $20mm is still overpaying these hospitals…

“No one wakes up and says, ‘I want to go to the hospital,'” said Ayesha Clarke, interim director of the Hartford-based nonprofit Health Equity Solutions. “However, when it happens, seeking care should not result in a lifetime of financial hardship.

It’s been our experience over the years most Plan Sponsors never read their TPA administrative agreements. As an example, some years ago a client approved their ASO agreement without first allowing us to review it as was required under our management agreement. They screwed themselves and I had to tell them they screwed themselves. Sugar coating has never been our style.

The Mercedes Independent School District can’t decide what to do…………….

Article Referred By Dan Meylan

LOUISVILLE, Ky.–(BUSINESS WIRE)– Humana Inc. (NYSE: HUM) today announced that it will be exiting the Employer Group Commercial Medical Products business, which includes all fully insured, self-funded and Federal Employee Health Benefit medical plans, as well as associated wellness and rewards programs.

“The market is going there,” said Larry Van Horn, associate professor of management, law, and health policy and executive director of health affairs at Vanderbilt University. “You’ve got direct primary care, you’ve got physicians going and moving into cash pay. You’re gonna have to sit there at some point and say, ‘Wait a minute, they’re taking my business.'”

“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.

We’ve experienced record growth over the past 24 months, and this has produced opportunities for us to better scale our business.  

Patient refuses to pay $75 for a two minute doctor visit. If more patients questioned what things cost before receiving services there would be no such thing as a balance bill. And it would be a good first step towards solving the high cost of health care in this country.

“I’m a little confused, how long have you been dead?” I asked in an open ended way.……………………..“Oh well now. A while. It must be a while.” The gentleman replied, with hestitation.

During the 17-hour operation, surgeons removed Andy’s diseased organs. He then received the following deceased donor’s organs all together and at the same time: liver, stomach, pancreas and duodenum (pancreaticoduodenal complex), spleen, small intestine and right colon.

This is why we don’t bid on insurance consulting services………………..

Cash pay health plans, funded through employer sponsored plan assets, are the future of group health care benefits for working Americans. Savings over insurance based health care are 50% and more.

“I just do not see the value of insurance if essentially I’m paying four times more to use it on top of paying a monthly premium and on top of marching towards a deductible,” Edwards said. “It is no longer a good value proposition.”

The way it works is that Sidecar issues its insured members what’s basically a debit card that they use to pay for care, prescriptions, and consultations directly. The money comes from Sidecar’s claims accounts and is paid directly to doctors.

Here at Zeihan On Geopolitics we select a single charity to sponsor. We have two criteria:

Retrospective underwriting can be a powerful marketing strategy. It has been used in the past with good success – write new business with scant regard of traditional underwriting parameters. In nine months you know what your picked up. At 12 months you run off the dogs and keep the rest.

Will the state continue to make up the shortfall for the TRS ActiveCare government health plan? Commercial carriers operating in the real world competing for Texas school business don’t enjoy that advantage. So how can the commercial carriers and third party administers compete? Sneaky underwriting?

So far there have been over 250 insurance related bills introduced in this Texas legislative session. We are seeing quite a few bills that will impact the growing market trend towards health care pricing transparency. Many of these bills will benefit Cash Pay Centric Health Plans.

If passed this legislative session, Texas HB 711 will forever change manage care contracts. Can you hear the BUCA posse thundering towards the upcoming sub-committee hearing…….?

Texas HB 633, if passed during this year’s legislative session, will provide broad application for Cash Pay Centric Health Plans, a growing market phenomenon. Cash pay health plans are the future of health care finance.

Texas A&M offers a medication assistance program for uninsured and underinsured Texans to obtain affordable prescription drugs through pharmaceutical patient assistance programs and foundation money.

TEACHER RETIREMENT SYSTEM OF TEXAS MEETING BOARD OF TRUSTEES

AGENDA February 16, 2023 – 12:00 p.m.

Discuss and consider selecting a pharmacy benefit administrator(s) (PBMs) to improve and enhance financial performance and services for public education employers, employees, retirees, and their families participating in the TRS-Care Standard, TRS-Care Part D (solicited as TRS-Care Indirect EGWP with Wrap PDPs), and TRS-ActiveCare……..

The following article describes the plight of one third of the population of Oklahoma who are on target to lose their Medicaid health insurance this year. The article does not mention 100% of those affected by the Medicaid cut will qualify for free hospital care under IRC 501r…………….and guess who is going to pay for all of this……………

NP practice owners assume the liability exposures of their practice, including those of their employees and independent contractors…………….evolving state licensure laws permitting NPs to practice more independently have contributed to the increase in percent and severity of claims.

Article Referred By Brent Evans – Sundown, Texas

West Texans are fiercely independent. There’s nothing a West Texan can’t figure out. When something breaks they don’t call for help, they fix it themselves. If they don’t know how, they figure it out. This fellow is no exception.

Pottstown’s superintendent Stephen Rodriguez said he was thrilled by the decision. “This decision is validation that our concerns with Tower Health were appropriate. They did not meet the measure of the law and should be paying their fair share of taxes and I look forward to them paying up.”

By Bill Rusteberg

“Do we have a Francisco Ybarra working for us?” asked the Sister. “Yes, he’s our grounds keeper” replied Maria in HR. “Ok, tell him Friday is his last day!” said the Sister of Charity……..“Now about this renewal offer……”

Texas Bill Would Require Law Enforcement to Carry Liability Insurance

A bill introduced last week by a Texas lawmaker would require law enforcement officers in the state to carry liability insurance as a condition of employment.

Professional Governmental Underwriters, Inc. is a full-service risk management company dedicated to assisting public, educational and non-profit entities in the management of their professional liability exposures.  Current operations are dedicated to underwriting and marketing Public Officials Liability, Law Enforcement Liability and Educators Liability insurance.

We are dedicated to providing state-of-the-art professional underwriting management and loss control advisory services on behalf of our designated carriers. We operate through a network of professional producers who seek specialized services for their public, educational and non-profit entity clients.