The EPISD board of trustees received an update to their self-funded health plan on April 5, 2022. Projected cost to provide coverage averages $10,500 per year per employee participating in the program. There are about 6,000 employees on the health plan. 6,000 X $10,500 = $63,000,000

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If Roe v Wade is overturned, will this change faith-based employer’s view on staying grandfathered? (more…)

Most residents in South Texas qualify for free hospital care under Hospital Financial Assistance Programs (HFAP) promulgated under the Affordable Care Act.

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A basic ACA compliant Minimum Essential Coverage (MEC) plan doesn’t do much for plan members. Rather, it is simply a strategy enabling employers to avoid certain punishing government mandates designed to force employers to the government’s will.

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By Michael M. Adams’

This image is what I think of when I hear “all our doctors must be in-network”

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“What network do you belong to? asks the in-take clerk. “I’m on the Medicare network” replied the member. “That’s funny, there is no indication of that on your I.D. card” responds the now puzzled in-take clerk. “Well, our group plan is on the Medicare +20% network, it’s sometimes called a Reference Based Pricing plan. Since you take Medicare patients already, you’re really gonna like our plan!” says the member. “Cool” says the in-take clerk.

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“You’d better believe the hospitals will go after you for every penny. Here’s a copy of a letter one of my patients brought me.”

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SOURCE: Hospital Billing | True Cost of Healthcare

“When a business sends a bill, to you or to another business, you pretty much expect the bill to show the value of what they provided, and therefore what they expect to be paid. But an insurance company pays the hospital based on pre negotiated rates, no matter what the bill asks for……………”

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Hospitals Look to Raise Treatment Costs as Nurses’ Salaries Increase – Health insurers and employers are pushing back against requests to increase hospital prices by as much as 15%….. (more…)

If open enrollment is held once a year to allow plan members to make changes, then in this case the cost for “enrollment services” is $72 per employee. An Open Enrollment period lasts 30 days so earning $300,000 in 30 days is $10,000 per day (with weekends off). 

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By Doug Aldeen – ERISA Healthcare Attorney and General Counsel

“Mama’s don’t let your sons grow up to be cowboys but a medical debt collector in the state of Texas is perfectly acceptable………”

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Psst, Godfather! The Cat’s Outa The Bag!”

“You don’t want me to know your business because it won’t be good for you.”

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Amazing things happen when vendors compete for business. With the passage of SB1444 by the Texas legislature this past session, TRS ActiveCare member districts are allowed, for the first time in 20 years, to exit the program and seek competitive alternatives in the commercial market.

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Borders are manmade lines. The Texas / Mexico border along the lower Rio Grande Valley segregates medical care givers into two different economic pods. Drug manufacturers serve both but with vastly different pricing models.

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The future of health care reimbursement is cash paid at the point-of-service funded by employers insuring over 170,000,000 Americans through work-place employer sponsored health plans. Screw insurance companies and other blood sucking third party intermediaries. (more…)

Specialty carve-out programs (also known as alternative funding programs) exclude most or all specialty drugs from the plan’s formulary. A patient technically has no coverage for the specialty drug. A third-party carve-out vendor helps the patient apply for the patient assistance funds from the manufacturer’s charitable foundation.

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For the first time in 20 years the TRS ActiveCare government health plan hasn’t raised rates or reduced benefits to plan members.  The Texas legislature has dumped hundreds of millions in additional funding cloaked as “Covid Relief” to keep the program solvent………….This has little to do with regional rating or anything else about controlling health care costs, which it doesn’t. More money-out with more money-in simply means more money…………… not less.

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“Now you can earn $100 per enrolled employee for every NEW Small Group (5 to 50 employees) you enroll into our Anthem Balanced Funding (ABF) plans, through 6/1/22 effective dates. Thereʼs no cap on how much you can make.”

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“Maine’s Democratic governor, Janet Mills, signed legislation directing the Maine Health Data Organization (MHDO) to report annually on the potential savings if certain drugs were subjected to a referenced rate, which is the lowest of the prices available among Canada’s four largest provinces and the wholesale acquisition cost, beginning January 1, 2023.”  MORE >>

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Watch a health insurance renewal presentation on a 450,000 life case unfold before your very own eyes! Will rates go up? Will benefits reduce? Or will something magical happen?

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“Blue Cross Members Get a Network with 95% of Doctors and 96% of Hospitals in the U.S.”

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“The most effective way to address the No Surprises Act (NSA) legislation, particularly elements of the Independent Dispute Resolution (IDR) process, may be to adopt a pure RBP plan that does not contract with providers……………….”

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Do you shudder when a prospect tells you they are diabetic?

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The open portions of the April 28, 2022, meeting are being broadcast over the Internet…….

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Texas hospital officials expressed relief that the future of the waiver was no longer in question but continued to push for other programs to help pay for the care of Texas’ uninsured population — the largest in the nation.

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By Doug Aldeen on Linkedin

In Alec Baldwin’s iconic role in the seminal 1992 movie, Glengarry Ross, he advised his underlings to “always be closing ” (“ABC”). In Colorado, for hospitals under HB 1285, “ABC” =always be compliant… .

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Government To Remove ACA Handcuff?

The Telehealth Benefit Expansion for Workers Act would allow employers to offer standalone telehealth service programs……………

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A reference based pricing plan having direct provider contracts is by definition a “network” plan. (See definition of “in-network” in Code of Federal Regulations, 147.210, XII) In that instance a plan sponsor must publicly display in-network information containing name, CPT code and negotiated rate and fee schedule rates.

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“Coming soon to a television near you: Our own Doug Aldeen is featured in this upcoming series on medical debt by our news partner KXAN TV in Austin, Tex.” – Jeanne Pinder – Founder, CEO, clearhealthcosts.com

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Car dealer’s approach to health insurance lifts employees and profits

As working Americans struggle to manage the rising cost of health care, one Lakeland car dealership has developed a new way of trying to close the door on higher costs.

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How do you compare financial performance between two group health plans? How do you determine which plan is outperforming the other in terms of dollars only?

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“It’s easy to get Medicaid, for sure,” Dr. Lazzopina says. “But just because you have a card doesn’t mean you’re going to get an appointment, at least any time soon.”

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Is government health plan financing simply a price fixing scheme having little to do with supply and demand resulting in constricted access to care in an otherwise (almost) free market system?

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By Bill Rusteberg

Sometimes we read things and wonder “what the heck were they thinking when they wrote this? Is there something I’m missing here!”

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John Kirke leads BevCap Management’s healthcare captive team, client services and growth strategies empowering clients to create value for their organization through healthcare benefits sponsored in stop loss captives.

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A.J. Loiacono Doesn’t Mince Words

Trying to understand the mystery world of American drug pricing will drive one to the nut house faster than you can spell P-H-A-M-A-C-E-U-T-I-C-A-L-S.

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By Bill Rusteberg

A patient in severe pain barges into the doctor’s office screaming “I need to see the doctor! I’m in pain, terrible pain! Please, tell the doctor I need help!”

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The DPC Coalition and American Academy of Family Physicians spent two years in collaboration with Milliman and the Society of Actuaries on a comprehensive evaluation of Direct Primary Care (DPC) as a growing health care delivery and financing model.

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By Bill Rusteberg

Years ago when I was a sales representative for a health insurance company a disgruntled plan member cornered me, screaming her claim was denied. “Our insurance sucks! I pay a lot of premium and I don’t get anything in return!” she screamed for all to hear.

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Last fall the Texas legislature gifted the TRS ActiveCare health fund +$200,000,000 and called it “Covid Relief.”

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Specialty is a growing specialty insurance Company, delivering commercial property and casualty products and solutions on a non-admitted and admitted basis.

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Santa & His 435 Elves (Congress) Declare Xmas In The Spring!

Other people’s money would help offset the high cost of coverage in employer-sponsored plans……….

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Hub continues acquisition spree

by Ryan Smith 11 Apr 2022

Global broker Hub International Limited has announced that it has acquired the assets of Marketing Management Associates. The terms of the transaction were not disclosed.

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Dream vacation for the uninsured………………………….

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One hospital wants an 88 percent higher reimbursement for its providers in the next four years…………Another hospital wants a 30 percent overall rate increase, including a 50 percent increase for some services…………

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“I successfully defended my dissertation titled: A CASE STUDY OF GROUP HEALTH INSURANCE COVERAGE AT ONE TEXAS SCHOOL DISTRICT, earning an Ed.D. from Lamar University. My dissertation was a single case study of group health insurance coverage at Raymondville ISD. “ – Ben Clinton

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The Department of the Treasury (Treasury) notice of proposed rulemaking on the “family glitch” expands eligibility for free government money to employees’ families when their share of their employer-sponsored premium is deemed to be unaffordable by  faceless bureaucrats in Washington.

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A direct primary care organization (DPC) charges $60 per member per month or $720 per member per year. According to government statistics PCP visits per 100 = 136 or 1.36 visits per person per year.

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Failure to comply with new community health needs assessment rules under the Affordable Care Act resulted in a non-profit hospital losing its tax-exempt status back in 2017. Has there been other cases like this since?

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Failure to meet these requirements can have significant consequences……………….

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Hospital Administrator & Family Attend Movie Premiere

What if you could protect employer health plans and their members from excessive and often incorrect hospital charges? Watch our fast-moving 30-minute video with Doug Aldeen, prominent healthcare and ERISA attorney, and learn how to challenge and change this costly dynamic.

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“Recently we asked a not-for-profit hospital for a copy of their Financial Assistance Policy. Instead they directed us to their website where, they said, we could find all we needed to know about their Financial Assistance Policy. We did, and it didn’t. So we asked the hospital a second time for a complete copy of their Financial Assistance Policy. To date they have not responded. So, it’s been over 30 days now and it’s time to file a complaint with the proper federal authorities to remove their not-for-profit status. They can’t have their cake and eat it too” – Bill Rusteberg

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Leslie Donovan followed the blueprint I laid out in “Never Pay the First Bill” to sue Sutter Health, leading to a refund and cleared balance.

Marshall Allen

4

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Vendors, We are opening the bid for RFP-0422-SI, Student Insurance. Please go to the link below:

https://sbcisd.edlioschool.com/apps/pages/index.jsp?uREC_ID=900856&type=d&pREC_ID=2305758

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With great sadness we announce the passing of Nola Ortiz. Nola is survived by her three sisters, Ava, Allie and Anna and Boudreaux (Buddy) Wilson III.

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Employers these days are subject to government oversight to an extent never envisioned by our Founding Fathers. Failure to comply with onerous government mandates can lead to crippling punishment at the hands of faceless bureaucrats lurking within the Deep State……………..

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By Scott Fuqua on Linkedin

(Experienced Healthcare Professional with nearly 25 years in the industry. RBR, Medical Bill Review, Cost Containment)

If PBMs could lower the cost, why are they not doing so? Just like the PPO Network middle men, the traditional PBM model is an absolute PROVEN FAILURE.

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Sunday Morning Bathroom Read, Spring Edition, Vol. 1, Article 1

“Now we can confirm why the person hit by the semi was marked as COVID on the death certificate” – Doug Aldeen

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Registration is now underway for Summer Session 2022, A Public Purchasing Seminar! Join ISM-RGV at South Padre Island, June 22, 23, 24, 2022……Learn about public purchasing laws affecting you and your entity.

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Doctor Working Under Pandemic Stress Pressures

“Experts” warn that the man-made Chinese Flu pandemic, now entering its third year, has pushed primary care workforce towards rapid extinction……..20% of primary care physicians intend to quit………..the rest are being swallowed up by the hospital industrial complex at a rapid rate…………

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Miracle Mike Before His Transformation

Most plan sponsors are chickens, too afraid to step away from status quo health care strategies that don’t work and never will. They all share common roots according to historians.

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When a self-insured plan sponsor doesn’t audit weekly claim check runs bad things can happen………….  

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By Bill Rusteberg

A Texas state government health plan established 20 years ago as a solution to rising health care costs incorporates a legacy, status quo managed care approach that hasn’t changed since it started.

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MAY 12-14, OMNI FORT WORTH HOTEL, FORT WORTH, TEXAS

JOIN US MAY 12-14 FOR THE EVENT DEDICATED TO DIRECT CARE STRATEGIES AND ADOPTING FREE MARKET PRINCIPLES IN HEALTHCARE.

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“After encountering pushback from insurers and claims administrators, out of network providers have sued to recover reimbursement for thousands of claims, primarily arguing that the CARES Act provides them with a private cause of action for reimbursement at the at ‘cash price’ they listed on their websites.

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Millions of dollars in questionable expenses, a generous administrative payroll, high executive turnover and rising health care prices……………Unlike health insurance companies, which are subject to regulation, the trust does not answer to the Department of Insurance. For years, there have been complaints of impropriety, and expenditures have been hidden from public scrutiny……

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Travel agents and stockbrokers are nearly gone the way of the dinosaurs and so will PPO networks and status quo benefits brokers………………….

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In a testament to the power of science, and beer — researchers in Switzerland outfitted a 36-year-old ALS patient with a chip in his brain, which allows him to spell out sentences one letter at a time, and he used it to order up a cold one.

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By Eric Bricker

Google Announced It is Creating a New Healthcare Stop-Loss Company Called Coefficient. Coefficient Will be a Part of the Verily Healthcare Subsidiary Within Google.

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“Double your pleasure, double your fun with double mint, double mint, double mint gun.”

NEWEST VERSION: Double your pleasure double your fun with the best double priced discounts found under the sun …………….Hurry buy our health insurance and get a 50% discount off double the price! Call now and talk to one of our licensed agents, plus get your free gift – only good for the first 25 callers! Hurry…………………….Call 867-5309 and ask for Jenny

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A leading provider of Reference Based Pricing…….oops, I mean Workers Compensation Insurance which is a Reference Based Pricing health care payment strategy…………..

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PBMs: The “Tapeworm” Revealed

How is it that the process of distributing a drug and tracking who buys it sucks up much more of the value chain than actually making it?

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By Bill Rusteberg

In 1982, after nine years of corporate servitude, I left the inner sanctums of a large health insurance company and the comfort of receiving a corporate paycheck every two weeks whether I earned it or not.

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By Bill Rusteberg

“Playing” health insurance brokers is the easiest sale ever. I was reminded of that today when a company rep. said “Bill, I never call on a prospect directly, I always work through the broker on the case. It’s the easiest sale ever. I don’t have to cultivate a relationship with the client. That can take years. It’s already been done by the current broker.”

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