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.
1st Year RBP Report Card
August 22nd, 2019How to Get Around ERISA Anti-Assignment Provisions
August 22nd, 2019
“There are three possible ways for providers to avoid application of the anti-assignment provisions in plan documents.
Texas School District Lowers Healthcare Costs While Improving the Quality of Care
August 22nd, 2019
“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
Beginning of The End of Group Health Insurance?
August 20th, 2019
$0 Investment Brings $2.4 Million Annual Return
August 19th, 2019
Is it true a South Texas Hospital system is buying up primary care practices to fatten up their cash cow?
The ‘follow-up appointment’
August 18th, 2019For 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)
The Misconception of Risk Pooling
August 17th, 2019
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.
San Antonio Suspends Paid Sick Leave Law
August 16th, 2019
“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.”
Hospital Bills 1661% of Medicare
August 16th, 2019
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!”
The Cost of Convenience
August 16th, 2019
“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.”
Selecting a Third Party Administrator
August 16th, 2019
By William Rusteberg
With the growing suggestion that the BUCAs are inflexible third party administrators unwilling and unable to administer Reference Based Pricing plans and other strategies in the market today, more brokers are seeking new partnerships with independent third party administrators (TPA). An independent TPA can offer much more than a traditional carrier model.
August 15th, 2019
“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
Why Some Doctors Purposely Misdiagnose Patients
August 15th, 2019
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.
Off The Record
August 15th, 2019
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.
August 14th, 2019
Texas and Colorado issue cease and desist orders to health care sharing ministry………
Hospital Administrator Morphs Into Insurance Sales
August 14th, 2019See hospital administrator morph into an insurance broker before your very own eyes…………….From Hospital administrator to power broker in under five minutes…..
Health Insurance Choices Could Get Your Client Deported
August 14th, 2019
New immigration regulations leave coverage purchased with ACA subsidies off the list of positives.
Brownsville ISD Insurance Commttee
August 13th, 2019If you are a new era health insurance consultant this video will drive you nuts.
To Save Money, American Patients And Surgeons Meet In Cancun
August 13th, 2019
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.
North Carolina Caves – Hospitals Win Big
August 11th, 2019
Private Payers Pay 2.7 Times on Average What Medicare Pays Hospitals
August 11th, 2019
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.
The Phia Group Launches Newest Service: Patient Defender
August 11th, 2019
Health plans, TPAs, and brokers can now contain costs while knowing that patients have a legal advocate standing by.
Recent Health Plan Practices That Are Resulting in Underpayments to Providers
August 10th, 2019
“Anthem is determining whether an outpatient MRI, CT scan, or PET scan is “medically necessary” based on where the service is performed.”
Do Hospitals Charge More to Make Up for Low Government Pay?
August 9th, 2019
Risk Payment Models
August 9th, 2019
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………………..
Health Care Is Gobbling Up Your Wages
August 8th, 2019
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.
Union Urges School District To Consider New Era Health Care Strategies
August 8th, 2019
The Brownsville Independent School District, like many public schools across Texas, is facing mounting, crippling health care costs through their self-funded health insurance program.
Destroying Relationships
August 7th, 2019
“What do you do for a living?” asks the neighbor. “I destroy relationships” replies the salesman.
Oh Oh, Novartis Hid Manipulated Data
August 7th, 2019
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.
The Power of Labor Unions In Addressing Health Care
August 5th, 2019
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.
Million Dollar Mike
August 5th, 2019He makes millions, threatens to deprive teachers, state employees, retirees and their families of affordable health care coverage.
Profiting From The Poor
August 4th, 2019
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.
Innovative Defined Contribution Plan
August 4th, 2019
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.
HEALTH FUND REFUSING TO PAY FOR LIFE-SAVING DRUG
August 4th, 2019
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………………
New Drug Costs $2.1 Million – A Plan Sponsor’s “Poison Pill”
August 4th, 2019
“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.
Tooth Fairy To File Bankruptcy?
August 2nd, 2019
Seven year old boy files Tooth Fairy claim…………….No-limit tooth provision to set record reimbursement rate……….Tooth Fairy spokesman hints at bankruptcy…..
Trump Administration, In Shift, Announces Plan To Permit Drug Importation
August 2nd, 2019
“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…………………….”
School Gives Raises, Health Insurance Takes It Away
July 28th, 2019
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………………..
Doctors Hospital At Renaissance Flexes Political Muscle in Deep South Texas
July 27th, 2019
Fort Worth Projecting $11 Million in Healthcare Savings in 2019
July 26th, 2019
“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.”
Watch Aetna, Blue Cross, United Healthcare & Independent TPA Give Their Sales Pitch
July 26th, 2019The 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.
Medicare Provider Utilization & Payment Data
July 23rd, 2019
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
End Surprise Medical Billing
July 23rd, 2019
“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.”
Surgical Company Sees Big Money Opportunity In Texas
July 22nd, 2019
Each investment would be $15 million, with an estimated 30 percent return on investment each year for a decade……………..
How The Eastern Cherokee Took Control Of Their Health Care
July 22nd, 2019
“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.”
Middle Class Anger Over Health Care Costs At Tipping Point
July 20th, 2019
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.
TRS Seeks TPA Services
July 19th, 2019
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………….
Is Texas Single Payer Government Health Plan Imploding?
July 18th, 2019
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.
Texas Addresses Free Standing ER Price Gouging
July 16th, 2019
With the stroke of his pen, Gov. Greg Abbott signed into law some of the strongest patient protection laws in the nation to shield Texans from the financial pain and misleading practices of free standing emergency rooms, where patients face a more than 80% risk of being balanced billed.
Why Hasn’t Texas Joined The Reference Based Pricing Revolution?
July 16th, 2019
Feeling Lonely?
July 16th, 2019
Could You Be Supporting a Hidden Retiree Health Plan?
July 16th, 2019
A retiree health plan is when ex-employees are provided for or allowed to purchase health care through their former employer.
Slapped in North Carolina
July 14th, 2019
“Delay and Confuse” is one of the oldest tactics used by incumbents under attack. The North Carolina flirtation with Reference Based Pricing for their state employees is a classic example.
Ortiz Joins RiskManagers.us
July 13th, 2019
“Nola’s commitment to excellence and her dogged approach to problem solving fits in perfectly with our culture here”
CarynHealth
July 13th, 2019
When Mike Dendy is involved, it’s golden. Introducing CarynHealth……………
Hospital Official Reacts To RBP- “Burn In Hell You Sorry SOB’s”
July 12th, 2019
Mention Reference Based Pricing to a hospital official anywhere and you may experience first hand a human meltdown unfold before your very own eyes……………….
“Burn in hell, you sorry SOBs. Your plan to cut payments to hospitals could possibly be the most moronic idea I have ever seen come out of state government, and since you retardicians have taken power, and that’s saying a lot………….poor people generally don’t vote for your party, so you want them to die.”
Doctor On Demand Going Viral
July 11th, 2019High Cost Of Insulin Sends Americans To Canada To Stock Up
July 10th, 2019Knowing The Answer Before You Ask But Hoping Otherwise
July 9th, 2019
Working The Spread
July 8th, 2019The Case of The Two Legged Stool
July 8th, 2019
The ACA is a naked command to buy an insurance product the government deems suitable,” Texas Solicitor General Kyle Hawkins argued in court papers.
“Bereft of penalties, the mandate now raises no revenue and therefore cannot by any conceivable definition be considered a tax,” he added. “Stripped of its tax status, the individual mandate is nothing more than an unconstitutional congressional mandate to purchase health insurance.”
North Korea Reinsurance Broker Launches New Website
July 8th, 2019
North Korea’s “first” insurance, reinsurance broker launches new website
Judge Shoots Down Association Plans
July 7th, 2019
A federal judge has rejected the Trump administration’s rules for association plans………….
Proposed Rules Would Affect Prescription Drug Plans
July 7th, 2019
Since the passage of the ACA un-elected bureaucrats in Washington have been issuing regulations faster than a melting raspa on a deep South Texas afternoon in August. Now the focus is on whorehouse high prescription drug costs…………
New Stop Loss Trademark Coined By Client
July 5th, 2019
Final Rule On Health Reimbursement Arrangements Could Shake Up Markets
July 4th, 2019
Ruling will fundamentally change the way employers provide employee health care benefits……..
Foundational Concept of Managed Care Under Siege
July 3rd, 2019
Managed Care Castle Under Siege
If current proposals come to fruition, the issue of narrow networks or surprise billing will no longer be the consumers’ problem………providers could be left holding the bag if their ability to negotiate is undermined by disclosing rates to managed care entities …….the need to contract could conceivably be impacted and the foundational concept of managed care could break down.
OBAMA CARE IN FOUR SENTENCES
July 2nd, 2019
Is there a single soul who is surprised that an engineer came up with this? The 10,535 pages of the Obama Care legislation reduced to 4 short sentences.
State Passes First Third-Party Auditor Bill
July 1st, 2019
bill that some insurers lobbied quietly to quash made its way through the Legislature and was signed by Gov. Phil Murphy on Sunday.
French Work Ethic Crosses Atlantic – Lands in New York
July 1st, 2019
“The French are on vacation more than they’re at work.” “They can’t wait to get laid off so they can live off generous unemployment.” “They have no ambition.” – (secretsofparis.com) Read the rest of this entry »
Lawsuit Alleges Rx Price Fixing
June 30th, 2019
Unintended Consequences?
June 28th, 2019
“340B is a well-intentioned drug discount program gone awry………..” Has the program departed from its statutory foundation?
Senate Panel Makes Surprisingly Fast Work of ‘Surprise Medical Bills’ Package
June 27th, 2019
“Members of the Health, Education, Labor and Pensions (HELP) Committee approved a sweeping measure Wednesday that tackles a range of big-ticket health care concerns.