By Jeanne Pinder

We’re live with CBS national news! We’ve been promising big news for a while now, and here it is…….

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Cash payment claim strategies often saves more than what the plan would have otherwise paid proving providers will accept less reimbursement for cash………………..

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Freedom Health 100 is proud to announce a new group health insurance product  – The Freedom Health 100 plan.

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You never know who is behind the insurance curtain. You may think you have insurance with ABC Insurance Company,  but they may only be the “fronting” company retaining only a small portion of the risk. You might be insured with 20 or 30 carriers through a reinsurance treaty, each sharing in the risk on a prorata basis. 

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You’re negotiation skills suck!

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“They are using our money, so overpaying there is no consequence to them………So it is easier for them to pay the bills as they come in, whether they are appropriate or not……………..”

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By Bill Rusteberg

School districts are entitlement based bastions whose decision making processes heavily weight social considerations at the expense of prudent business practices.

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Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.

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Recent court decision is a reminder that health plan fees must be monitored and that a good fiduciary process is always the principal defense to claims of fiduciary imprudence.

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The job pays $65,000 per year plus benefits. By the time we add up all the benefits including health insurance, workers compensation, FICA, etc., your job is worth $85,000.

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By Bill Rusteberg

A favorite strategy to lower health care costs by plan sponsors is to change the logo on one’s I.D. card.  Everything else remains essentially the same.

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Brownsville and Harlingen in deep South Texas leads the country in the highest health care costs with a markup rate of 940% of Medicare, followed by three other nearby cities of McAllen, Edinburgh and Mission……………..

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“In the real market, healthcare costs are flat.” – Dave Chase.

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You won’t see recognizable logos or insurance company names on their health insurance I.D. cards. You may wonder “what kind of insurance is this?”

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By MATTHEW HAHN, MD | POLICY |

What happens when you place an entire nation’s health care in the hands of an overly-controlling, ineffective government bureaucracy and huge corporations whose mission it is to squeeze as much money from the system, no matter the cost, including people’s lives? You get the carnage that is the American health care system.

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Medical trend continues to outpace general inflation. Those plan sponsors who abide by the law of civil obedience continue to fund the health care beast’s insatiable appetite while others are taking a different approach. The later have solved health care……….they have stopped feeding the beast…………

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By Molly Mulebriar

There is only one proven method to control specialty drug costs……… 

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A seemingly valid concern about Reference Based Pricing strategies on the part of consumers is the possibility of balance billing leading to personal debt, lawsuits and ruined credit. Balance billing occurs when you don’t ask the price……………

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The State of Texas has filed a lawsuit seeking to stop Aliera Healthcare from selling health insurance in Texas and engaging in the business of insurance without a state license.

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More than 50% of doctors are now in employee positions and generally beholden to “big medicine” so that doctors’ fidelity is primarily to the hospital system that employs them and away from patients.

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By Bill Rusteberg

Mr. Sidgwick: “Self insured plan wants to cap payments made for air ambulances to some arbitrary number, $20,000 for example. Does it matter that this is for emergency care, and is this an essential health benefit under the ACA?”

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For a free copy of Dave Chase’s best seller go here: healthrosetta.org/friends/

Great leadership, great students……………..

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A Texas judge has ordered Richardson’s Blue Cross Blue Shield of Texas to pay more than $21 million to Knox County Hospital……

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The law limits co-payments for a 30-day supply of the life-saving drug under private insurance plans to $100. It does not change the price of insulin…………………

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Blue Cross has successfully hijacked the term Reference Based Pricing  –  a damn smart marketing move……………………

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A mid-size Texas employer went from a BUCA to a Reference Based Pricing plan last year. The benefits remained the same. However, a change was made in the way providers are paid.  In lieu of paying through secretive managed care contracts, the plan paid medical providers based upon a transparent reimbursement schedule tied to a percentage of Medicare allowable charges.

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“There are three possible ways for providers to avoid application of the anti-assignment provisions in plan documents.

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“Managing health care on a local level brings needed accountability to health care financing while providing improved access to care and higher patient satisfaction. The patient-physician relationship becomes more than just a ten-minute office visit; it becomes a true partnership.”  – Alex Zuniga

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Will HRA’s replace group medical plans?

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Is it true a South Texas Hospital system is buying up primary care practices to fatten up their cash cow?

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For many people in medical debt, a trip to the emergency room leads to the courtroom

Wenzle Hufford, 76, uses a rope to tow his wife, Lucynda, with his motorized wheelchair in Kennett, Mo. Both have large medical debts. His legs were damaged when he was hit by a car; she has diabetes and heart problems. (Michael S. Williamson/The Washington Post)

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By Bill Rusteberg

As members of the +400,000 member TRS ActiveCare risk pool “The Power of Large Numbers” and “Economies of Scale” bring comfort to small Texas school districts . “We could not get comparable coverage on our own, much less at affordable rates” is the mind thought of school district officials throughout the state.

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“San Antonio has agreed to delay implementation until December 1, 2019. The stay will allow time for guidance from the Texas Supreme Court on the law’s constitutionality. In the meantime, San Antonio’s Paid Sick Leave Commission has agreed to work with business stakeholders to recommend changes in the ordinance to the San Antonio City Council.”

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Hospital billed charges total 1661% of Medicare. A typical PPO “discount” would be between the range of 50-70%. If the later, the hospital would be paid about 498% of Medicare. Plan paid 180% of Medicare. Hospital still wants more money. Plan sponsor says “Not in my lifetime!”

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“Those trying the preserve the wildly under-performing and bankruptcy-inducing status quo healthcare system will do whatever it takes to try to thwart progress” – Dave Chase

In his time at the hospital, from 1999 to 2007, his salary rose from$185,000 to $300,000, and he qualified for bonuses up to $220,000 if he met certain billing targets.

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By Bill Rusteberg

While visiting Washington DC last year on business, I ended each day with a short visit to Off The Record, a bar located at the Hay Adams Hotel across the street from the White House. This place is always packed with interesting people and I had occasion to meet a few of them. 

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Texas and Colorado issue cease and desist orders to health care sharing ministry………

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See hospital administrator morph into an insurance broker before your very own eyes…………….From Hospital administrator to power broker in under five minutes…..

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New immigration regulations leave coverage purchased with ACA subsidies off the list of positives.

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If you are a new era health insurance consultant this video will drive you nuts.

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A knee replacement surgery costs an average of about $30,000 at U.S. hospitals, but only $11,000 at Galenia Hospital in Cancun, Mexico.

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“By spending millions of dollars to oppose us and by using cartel-like tactics, these organizations were able to convince most hospitals to boycott the State Health Plan,” said Treasurer Folwell. “If big hospitals could do this to their largest customer, just think what they can do to the individual average citizen or business.

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With the lid ajar on Pandora’s box, we are likely to see employer demands pegged to price transparency and more strategies built on provider prices.

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Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.

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“Anthem is determining whether an outpatient MRI, CT scan, or PET scan is “medically necessary” based on where the service is performed.”

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Answer: “NO”. Hospitals charge as much as they can get away with…..

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Risk payment models present a daunting challenge to the very cultural of medicine—for most physician practices. Physicians identify their practices as clinical enterprises more than businesses………………..

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SOURCE: Axios

“In 1999, the average health insurance coverage for a family consumed 14% of the average household income …  By 2017, family coverage absorbed more than double that amount, to about 31% of take-home pay.

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“What do you do for a living?” asks the neighbor. “I destroy relationships” replies the salesman.

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Approved in May, the treatment’s price — set at $2.1 million — stoked concerns about the astronomical costs of potential cures for rare diseases and upset parents who initially could not get insurance coverage for the breakthrough treatment.

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Once labor unions learn the truth about what’s driving health care costs and become aware of proven methods to reduce costs while improving benefits at the same time, they will become a powerful force for change.  

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He makes millions, threatens to deprive teachers, state employees, retirees and their families of affordable health care coverage.

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The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

Nonprofit hospitals pay virtually no local, state or federal income tax. In return, they provide community benefits, including charity care to low-income patients. In Memphis, Methodist Le Bonheur Healthcare has brought 8,300 lawsuits for unpaid medical bills in just five years.

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Innovative Defined Contribution plan now available for groups of up to 99 employee lives. This could be a value add to small group health plans such as those available through Allied National (www.Alliednational.com) and others.

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There is only one known cure for the disease……… however the drug, priced at $2.1 million, is too expensive and not covered by health fund……toddler has only one more month to receive a new drug that could cure him………………

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“Specialty drugs account for about 1% of prescriptions but 95% of prescription costs.” A new drug approved this year will bankrupt health plans……………..Plan sponsors should carefully study their Rx formularies to determine if there are other “Poison Pills” lurking…….then take action.

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Seven year old boy files Tooth Fairy claim…………….No-limit tooth provision to set record reimbursement rate……….Tooth Fairy spokesman hints at bankruptcy….. 

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“These manufacturers would be able to use a new National Drug Code (NDC) in doing so, possibly enabling them to offer lower prices than are available under their existing distribution contracts…………………….”

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The end of PPO’s may be coming to an end sooner than we thought…………..

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A large Texas school district recently approved an across the board 4- 4.78% pay raise. Or is that number really 1% before taxes? The difference goes to area medical providers in the form of higher health care costs memorialized within secretive managed care contracts crafted by third party intermediaries. If the district had taken better advice, they could have lowered their health care costs 15-25% without a reduction in benefits, thus giving their employees a significant raise this year. Other Texas school districts are doing just that………………..

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“The hospital opened in 1997 and has recently become a force to be reckoned with”…………..Much has changed since the following article was written in 2009 and it hasn’t been an erosion of influence…..

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“Hospital systems are seen as the evil empire, and facility costs are seen as driving healthcare expenses,” Dickerson says. “So we tried to keep people from going to hospital system.”

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The Brownsville Independent School District recently went out for Request for Proposals for TPA services for the district’s self-funded employee health plan. The four finalists include Aetna, Blue Cross, United HealthCare and one independent TPA.

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Mission Impossible Assignment for Plan Sponsors

Nothing is secret about health care costs although many third party intermediaries wish it so. Piecing all the data towards responsible stewardship of an employer sponsored health plan is not impossible. Reviewing managed care contracts is not impossible either. Once I was told I would never get my hands on a Blue Cross hospital contract. I did. – Bill Rusteberg

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“If Congress cannot address even obvious market failures in private health care, a federal takeover of our entire health-care sector will become that much more attractive.”

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Each investment would be $15 million, with an estimated 30 percent return on investment each year for a decade……………..

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“It doesn’t look like a hospital, and it doesn’t feel like a hospital,” Kristy Nations said on a recent visit to pick up medications at the pharmacy. “It actually feels good to be here.”

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American Health Care: If you’re poor it’s free, if you’re rich it’s affordable, but if you’re a middle class American you’re screwed.

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A quick read of the minimum requirements knocks out all TPA’s except the BUCAs. This will be a bidding war between Aetna (incumbent), Blue Cross and United HealthCare. Smart money is on Blue Cross. Sadly though, changing the logo on the I.D. card won’t solve the problem of runaway health care costs………….

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The TRS ActiveCare program is a ticking time bomb for Texas conservatives and a point of light for Texas liberals. Unless it’s fixed quickly Texas will become a Blue State faster than a melting raspa in deep South Texas on an August afternoon.

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