Uncategorized – Page 2 – Risk Managers

FTC Consent Order Forces Structural Rewrite of How PBMs Operate

“This consent order more consequential than almost any reg or law to be considered in the last 5 years!”

Hospitals Blame Medicare To Justify Gouging Commercial Payers

“It’s remarkable how they’ve managed to perpetuate the narrative of “losing” money on Medicare. Have to hand it to their PR/marketing departments & lobbying arms for pulling that off.” – Dave Chase

Committee For Responsible Government Budget Spotlights Huge Reference Based Pricing Savings

Hospital Administrator Reacts

Stunning report that surprises no one concludes Reference Based Pricing will save government funded health plans a butt load of money. Who would have thought?

Escape The Volatility of Stop Loss Lasers – The Hot Potato Method

By Spencer Smith

For employers looking to escape the volatility of stop-loss lasers and massive renewals, The Samaritan Fund Program offers a unique path forward.

5 Reasons Businesses Are Abandoning Traditional Health Insurance

By Wiley Long

Most won’t surprise you. But #4 will change how you think about employee benefits. The evidence is overwhelming.

Revenue Cycle Management: Payer Mix Explained

By Eric Bricker, M.D.

‘Payer Mix’ is the proportion of patients w/ each category of health insurance.

Aldeen’s Sunday Morning Bathroom Read – Attila The Hun Addition

“If I were Atilla the Hun not for profit hospital CEO looking to control an entire universe and make a gazillion bucks along the way, I would…………”

$2,418 Hospital Facility Fee For A $93.40 Cortisone Shot

Patients are being hit with this surprise fee just for seeing their doc

Patients who visit hospital-owned doctors’ offices are discovering something that could make them feel sick to their stomach: a surprise “facility fee” unrelated to the medical treatment they receive.

TPA’s Response To Poor Performance

“It’s not our fault!” said the TPA, “The dog ate our homework!”

Follow The Money On A $100 Retail Prescription

Manufacturer sells $100 drug to wholesaler and nets back $5 to wholesaler
Wholesaler sells $100 drug to retail pharmacy and pharmacy nets back $2 to wholesaler
Retail pharmacy is reimbursed $114 by PBM (Claw back potential)
PBM earns $30 commission (rebate) from the manufacturer

ERISA Security Bond Is A Requirement For Most Private Sector Plan Sponsors

SOURCE: Surety Bonds Direct

A surety bond is a type of insurance that acts as a financial guarantee that a promise of performance and ethical behavior will be delivered as required by a contract or agreement. In simple terms, a surety bond protects customers or employees from purposeful theft or financial damage.

Are “Voluntary” Benefit Programs The Next Big Thing In ERISA Litigation?

Joseph C. Faucher

In late December 2025, the same law firm that initiated the wave of “excessive fee” 401(k) litigation matters in 2006 (which continues to this day) filed a spate of lawsuits alleging that several large employers (and their benefit consultants) breached their fiduciary duties under ERISA by allowing excessive or unreasonable premiums to be charged to their employees in connection with so-called “voluntary benefit” programs offered by those employers.

US Department of Labor Proposes Historic Pharmacy Benefit Manager Fee Disclosure Rule

Proposed rule would require PBMs to disclose compensation to self-insured group health plans

Prison Inmate Healthcare Management

SOURCE: TK Health

TK Health provides comprehensive health care services to diverse inmate populations, with services tailored to each client’s need. Our top focus is quality of care and quality levels of service, while providing accountability for use of taxpayer resources.

Albert

I saw this photo on Linkedin this morning and it reminded me of Albert, a South Texas native with one of the biggest set of brass cojones ever recorded within the insurance industry…………..

Cubanparency

Kudos to Mark Cuban’s for making the direct contracts his company has negotiated publicly available, with clear rate information embedded in them. The contract is here.

TPA Says It’s Impossible To Reprice Hospital Claims To Medicare

A TPA for a Reference Based Pricing plan was found repricing inpatient hospital claims at a % of billed charges instead using Medicare rates as the claim benchmark. When questioned the TPA sent the following email response:

“It’s impossible to reprice hospital claims to Medicare. Therefore, RBP repricing is approximated by paying a percentage of billed charges.”

Glenn McLellan

I’ve known Glenn for many years, lucky enough to have done joint work with him in the past. Without hesitation I would recommend his services to anyone who asks – Bill Rusteberg

How Do You Lose $60 Billion In 24 Hours?

By Dutch Rojas

QUESTION: How do you lose $60 billion in 24 hours? ANS: By breaking the one rule Wall Street still cares about.

How Do Average Rates Compare Among Texas Public Sector Groups?

SOURCE: TRS ActiveCare

The following tier rates (employee, spouse, children, family) are based on the monthly composite per employee cost shown in the chart above assuming statistical average participation by tier.

Allstate Benefits Is Now Nationwide

We are excited to share an important update. Effective February 2, 2026, your client’s Allstate Benefits group health plan will join the Nationwide family. This milestone marks the next step of the acquisition previously announced in July 2025. There is no impact to the plan, coverage, service experience, or administration — this is a name change only.

Nationwide Network of Independents Threaten Value Draining Intermediaries

“They are not the big national brokerage houses or the four major health insurance companies. They are small independent operators who have partnered with like-minded experts working in tandem towards a common goal.”

Cost Plus Drugs is Now at Your Local Pharmacy

SOURCE: Team Cuban Card

Switzerland’s Universal “No Single Payer” Health System

By Sheri Mancina M.D.

Switzerland Didn’t “Go Single Payer” when it reformed healthcare. Switzerland has universal healthcare, but it is not a government-run system. There is no national health service. There is no single government insurer. Doctors and hospitals are private. Insurance companies are private.

They separated access from profit. Here’s how the Swiss system actually works — in plain language:

Most Insured Individuals Use Relatively Little Health Care

The use of health care services — and the spending associated with those services — is far from evenly distributed across the population. It has long been known that a small portion of the population accounts for a disproportionately large share of health care spending, with 20 percent of the population typically accounting for
80 percent of total health care spending.

Mitigate Partners Is Worth A 10 Minute Call

The path of a prescription drug from the manufacturer to the patient is a long and winding road …” – Paragon Health Institute, 2026

Indemnity Health Insurance

What is an indemnity health plan?

An indemnity health plan will reimburse an enrollee for a portion of their healthcare costs, regardless of what medical provider the member uses or how much the provider bills.

How Three Communities Cut Healthcare Costs 20-50% and Redirected Savings Back to Employees

When Ashtabula reclaimed healthcare control, they saved $2.4M in year one with just 300 school district employees. That’s $8,000 per employee. The district went from dangerously low reserves to choosing how to spend their dividend: higher pay, better benefits, subsidized healthy food, restored programs.
Approximately $450 million annually flows out of Ashtabula County into distant corporate healthcare systems. A tremendous sum for a county of 100,000 people. That extraction weakens everything: wages, schools, economic opportunity, health outcomes.

Understanding IRS Section 501(r): What Employers and Employees Need to Know

Did You Know That 100,000,000 Americans Qualify For Free Care?

SOURCE: Memberly Benefits.

Healthcare costs can feel overwhelming for both individuals and employers. Fortunately, there are federal rules designed to ensure fairness in how nonprofit hospitals bill patients and provide financial assistance. One of the most important is IRS Section 501(r). Here’s a breakdown of what it is, how it works, and why it matters for employees, employers, and plan sponsors.

Meet Lesli Wood

Lesli Wood – Regional Vice President of Sales for Central/South Texas

She brings over 25 years of experience in the health benefits industry, with a proven track record in sales and account management at organizations such as Allied Benefit Systems and Humana. Her passion for building strong relationships and delivering exceptional service makes her a valuable addition to the Meritain Health Sales Team.

Highest Selling #Drug in America

“A full 2-year course of Keytruda can cost $385,000………………….”

Understanding the New Wave of ERISA Litigation Targeting Voluntary Benefit Plans

What Employers, Plan Fiduciaries and Brokers Need to Know

“These novel lawsuits challenging voluntary benefits are not only notable for what they allege, but also because they implicate consultants and brokers.”

100 Million People Qualify For Free Care

Meet The Bull

Dr. Bill “The Bull” Hennessey is a physician turned whistleblower who has spent decades exposing the fraud, waste, and abuse that cost Americans billions every year. Nicknamed “The Bull” for his aggressive, no-nonsense style, he has been featured on Dr. Phil, national TV networks, and investigative outlets, bringing hidden industry practices into the light.

Judi Health Unveils Launch of Advisory Firm, The Judi Group

stethoscope on red background with piggy bank — The Judi Group’s team will conduct “forensic-level” analyses across the vendors a plan sponsor works with to spot and remedy key issues, according to an announcement shared exclusively with Fierce Healthcare. (Kubra Cavus/GettyImages)

By Paige Minemyer Jan 20, 2026

Capital Rx A.J. Loiacono Employer-Sponsored Health Plan Healthcare Costs

Last fall, transparent pharmacy benefit manager Capital Rx rebranded as Judi Health in a bid to better reflect the breadth of the company’s portfolio.

Buying Loyalty

Carriers & TPAs Compete For Broker Loyalty

By Bill Rusteberg

Years ago when I was a commission driven insurance whore a TPA dropped by my office. “Bill, how many self-funded lives do you have on how many groups?” he asked. “Move 2,000 lives to us and we will not only pay you the same commissions you’re getting now but I will personally deliver a $250,000 check as our way of saying THANK YOU for the business!!”

Direct Provider Agreements

The sign of a good business deal is when both sides walk away happy……

By Bill Rusteberg

For mostly unreasonable reasons everyone wants access to provider agreements when seeking medical care. The term “In-Network” is forever imbedded in the American vernacular.

Aldeen’s Sunday Morning Bathroom Read – NSA Enforcement Dies

“Insurers will know that they can lowball their initial payment and then ignore a subsequent IDR award ordering them to pay more — and there will be nothing providers can do about it.”

Rx Rebates – Maximizing Revenue Through Deception

Hoodwinking – A Popular & Proven Sales Strategy

By Bill Rusteberg

The following illustrates two common practices in the insurance industry to maximize revenue through deception by hiding administrative fees and commissions on the claim side of the ledger with a little help from the PBM.

The Secret World of Stop Loss Insurance Pricing

By Daron Potts

Welcome to the self-funding jungle! Your client is at 60% of manual. They’ve run perfectly for three years. And their renewal is still going up. This is the pricing floor at work.

Illegal Aliens Cost Texas Hospitals Over $1 Billion in 2025

New data from the Texas Health and Human Services Commission surpasses earlier estimates.

President Trump Unveils The Great Healthcare Plan to Lower Costs and Deliver Money Directly to the People

The White House – January 15, 2026

President Donald J. Trump’s Great Healthcare Plan is a broad healthcare initiative that will slash prescription drug prices, reduce insurance premiums, hold big insurance companies accountable, and maximize price transparency in the American healthcare system.

TRS ActiveCare Out To Bid For 2026-2027 Plan Year

Award is expected to be made public in February 2026. Will Blue Cross retain the account? Or will Aetna win the Musical Chair competition against Blue Cross once again? Will United HealthCare win on a toss? Or will all three win, each awarded designated geographic areas where they have the best “discounts?”

No Deductibles? No Co-Pays? Is This Texas-Based Health Insurer Too Good to Be True?

SOURCE: Texas Monthly

Curative says it can turn profits without its customers facing the usual out-of-pocket costs or high premiums. Economists have their doubts.

Bobby Kennedy Willfully Violates HIPP Regulations

“He’s got incredible health. Dr. Oz looked at his medical records and……

90 Degree Benefits

90 Degree Benefits is a national third-party administrator (TPA) specializing in unique health plan solutions, including self-funding and level-funding. With more than 23 local offices across the U.S., our team provides the regional expertise brokers and employers need to take their health plan in the right direction.

Tx. HB. 4144 Expected To Turbocharge Critical Illness Sales

Texas has passed legislation gifting insurance brokers a golden opportunity to sell critical illness policies to Texas political subdivisions.

Ass National Insurance

A Cash Pay plan member goes to a medical provider. Since cash is accepted everywhere there’s no need for a network of “preferred providers.” The member is free to go anywhere and is universally viewed as a “preferred customer.”

Oh Oh

One For The History Books – Texas School District Paid $68,375 In Monthly Commissions To Health Insurance Agent

The La Joya Independent School District has a long history of generosity going back decades. Ruth Villarreal can attest to that. Generous servings from the district’s self-funded health plan honey pot have been a source of untold wealth for Ruth, a local insurance agent with connections.

$68,375.00 per month, for each month remaining on the original term of this agreement at the time of termination.
Continue reading One For The History Books – Texas School District Paid $68,375 In Monthly Commissions To Health Insurance Agent

Experience Freedom From Health Insurance

CrowdHealth is not an insurance company, but a platform & community that empowers you with a crowdfunding tool and a wealth of resources to efficiently manage your health care costs.

Republican President Mandates Government Price Fixing

Bernie Sanders rejoices at the news. “This is historic! The Republicans are finally coming around!”

The Real Reason Hospitals Are So Expensive

“Percentage of savings fees is the greatest fraud foisted upon consumers since Victor Lustig sold the Eiffel Tower in 1925. To earn 24% of an inflated, arbitrary number that no one ever pays is better than robbing a bank.”

Free Audit Lift Benefits Brokerage

(This post first appeared on this blog January 1, 2016)

A new company in town is shaking up local insurance brokers by offering to take a free look at what employers pay for benefits, to see if it can get them a better deal……………..

Competition breeds hostility in some people,” he said. “Bottom line: There aren’t any brokers who offer what we offer………….

Latest ERISA Cases from Schlichter Bogard Address Voluntary Benefits

The complaints allege breaches of fiduciary duty related to the premiums charged for accident, critical illness, cancer and hospital indemnity insurance.

Broker RFP Process Guide: How To Launch A Winning Benefits Broker RFP

By Bryan Davis – SOURCE: Nava Benefits.

Summary

A benefits broker request for proposal (RFP) can unlock crucial information about the employee benefits marketplace, your own total rewards offering, and the level of support your HR team could receive. But the RFP process can be time-consuming, confusing, and difficult — unless you’re well prepared. Here are four steps to get ready for a smooth RFP process.

United Airlines Let Their Broker Take 64 Cents Of Every Dollar Employees Spent On Insurance

By Dave Chase

United Airlines employees paid their broker 64 cents per premium dollar in year one. 64% went to Mercer as commission. Not to medical care. Not to claims. To the broker. Then it “improved” to 27% by 2023. Mysteriously dropped to 2% in 2024 when lawsuits started flying.

That’s not market pricing. That’s exploitation of weak oversight.

9,000 PPO Doctors Say “Adios”

9,000 physicians just walked out of Anthem’s network in New York.

What Took So Long? This Has Been Going On For Years!

By Dave Chase

For decades, benefits consultants operated under a simple protective claim: “We just advise.” Schlichter Bogard just demolished that defense & put them on a map no one wants to be on.

How To Stretch A 10 Second Decision To Infinity

A True Story By Molly Mulebriar

Take a ten second decision where everyone wins and nobody loses to a political subdivision then start your stop watch. You will be amazed how long a 10 second decision actually takes.

The Rise of ERISA Health Care Class Action Lawsuits

By Steve Ditto

Healthcare just crossed into its 401(k) moment. The law firm that forced fiduciary accountability into retirement plans has now filed healthcare ERISA class actions.

PBM Three Card Monte

By George H. George

Your PBM just charged your plan $2,847 for a prescription. They paid the pharmacy $340. They kept $2,507 as “spread.” You’ll never see it on your invoice.

No Surprises Act – Supreme Court Petitioned To Review Enforceability

Should the Supreme Court grant cert, the outcome of the case could have broad implications for the enforceability of NSA arbitration awards, a key feature of the NSA’s regulatory framework.

Private Practice Is Dead…..If You Take Insurance

“Here’s the truth, taking insurance can work but it’s very painful. You have to run a volume based practice, see lots of people and have complicated systems set up, for it to run well.”

Discrimination Runs Rampant In Legacy Health Insurance Plans

Illustration By Dutch Rojas – The Rojas Report

By Bill Rusteberg

Health insurance is a reimbursement benefit for a covered loss. Although plan members each pay the same premium, some receive greater benefits than others.

Do PBMs Know The Exact Amount of Rebates Per Prescription?

There’s been a discussion this week on Linkedin about whether PBMs can provide detailed quarterly rebate settlement accounting for plan sponsors.

RiskManagers 2025

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

100 Best Health Insurance Blogs and Websites in 2025 – RiskManagers.us ranked #10 in the 100 best health insurance blogs from thousands of blogs on the web ranked by relevancy, authority, social media followers & freshness.

Bette Nesmith

By Michael Magri

Dallas, Texas, 1954. Bette Nesmith was drowning. A divorced single mother raising her young son Michael on a secretary’s salary of $300 a month, she had dropped out of high school at seventeen.

Most Read RiskManagers.us Blog Article of 2025

Posted November 30, 2025 this blog entry has received +16,000 viewers, all in the past 60 days.

LBJ Signs Medicare Into Law – Was Ronald Reagan Right?

Medicare will be 60 yeas old July 2026. Was Ronald Reagan right?

City Gifts $2M to Local Hospital

City of Brownsville invests $2,000,000 in local hospital under Chapter 380 of the Texas Local Government Code.

The Myth of Nationalized Healthcare

The UK Health Care Disaster is a Cautionary Tale for America’s Rising Class of Armchair Socialists

The Washington Post shocked many of its Democratic readers this week by telling the truth about the growing disaster in the UK’s National Health Service — a cautionary tale as a few Republicans plan to join Democrats to extend the failed Obamacare subsidies rather than reform our own broken health care system.

A Surprising Treatment for Chronic Lower Back Pain: Cannabis

Two new drug trials find a THC-based cannabis extract could help with a condition that affects millions

6,240,000 Patients On Waiting List

There were 6.24 million individual patients waiting to get treatment in England as of October. That’s about 1 in 10 people in the country waiting in the queue.

Need Surgery But Don’t Have Insurance? No Problem………..

Pre-Existing Conditions Waived After 21 Days

Imagine needing some sort of surgical procedure but you don’t have insurance. No problem, book a flight to Costa Rica 21 days in advance, buy travel health insurance at the same time, and make your surgical appointment upon arrival at San Jose airport.

FLIGHT INSURANCE KIOSKS AND THE JET AGE

Travel Insurance Kiosks at Detroit’s Willow Run Airport, 1954. Part of the “Old News” collection at the Ann Arbor District Library.

SOURCE: FLIGHT INSURANCE KIOSKS AND THE JET AGE — Jet Age Art

While researching the fight insurance angle for my TGA (“Airport” movie) Ticket Package assembly, I discovered a rich, although brief history of airport flight insurance sales. It all started with the “Great Lakes Fidelity” Airline Trip Insurance Receipt I had to design, as a major component of the overall ticket package, as fans of the “Airport” movie or novel know.