Risk Managers – Page 42 – Thought Leadership on Health Insurance

Summer Session 2023: – A Public Purchasing Seminar

WHO SHOULD TAKE THIS SEMINAR AND WHY……….

This seminar will have class topics that emphasize cost savings to government entities. It is designed for persons having administrative responsibilities in the area of purchasing, especially applicable to all areas of the public sector including counties, municipalities, council of governments, state agencies, governmental funded non-profit organizations, and other special governmental districts.

Primos Transmission

Just In Case……………………………..

Primo’s Transmission is a third generation business located in Brownsville, Texas. I had occasion to use their services several weeks ago. I wrote a letter to the owner today, a young man with a rare business sense, a drive for excellence with a “Can Do” spirit, instilled by previous generations before him.

Do Providers Dispute BCBS Payments? Really? Which Ones?

Blue Cross Blue Shield has more contracted providers in-network than the beach has sand. So what’s the problem?

Daddy, What Do PBMs Do?

Little Johnny asks his savvy health insurance broker father “Daddy, what to PBMs do?

Shadow Pricing Risk

“We guarantee we will match or beat your renewal rates for better benefits!” says the health insurance broker. “All we need is a copy of your renewal and Summary of Benefits and we’ll have you a quote by end of day tomorrow!”

Mexican Prescription Drugs May Be Harmful To Your Health

A pharmacy in Nuevo Progreso. (Veronica G. Cardenas / For The Times)

“Her son had stopped at two drugstores in Nuevo Progreso, picking up Xanax at one and Percocet at the other. While the Xanax may have been legitimate, the Percocet was not.”

Government Requires Plan Sponsors To Lie

By the end of 2023 all Plan Sponsors MUST submit a fiduciary attestation to the DOL saying, “I’ve had no Gag Clauses since 12/27/2020.” Trouble is there is not a plan sponsored managed care plan on the entire planet that can honestly attest to that.

Easy Money – A True Story

Easy Money is a health insurance broker in the Lower Rio Grande Valley, Texas who makes his living bidding on public entities from the comfort of his living room couch. He’s a lone operator with no staff of his own and no office overhead to speak of.

Innovative Cost Containment Strategy

Doctors recommend plenty of fresh air and bed rest when one is down and out. A $100 tow truck provides a healthy environment and more bang for your medical buck than a stuffy, germ filled $2,000 ambulance box on wheels……………………..

Online Test Result: You’re Gonna Die

What’s better, going online and learning you tested positive for a deadly, low survival cancer or having your doctor explain, in a soothing reassuring manner, you have a deadly, low survival cancer? The message is the same so what’s the problem?

The Health Insurance Hustle

“Who’s at fault here? It’s not the broker. It’s not the insurance company either. It’s the plan sponsor who makes the system possible for what it is. They are in a position of power which most don’t understand they have. They should dominate the equation. A dominant fee based and experienced insurance advisor helps them do just that. “Me Too” fee based insurance advisors don’t. The later works for fees, the former works on principle.” – Bill Rusteberg

RX Strategy – The Greatest Good For The Greatest Number

If 400 low cost generic drugs can satisfy +90% of one’s pharmaceutical needs, how important is it to cover the remaining <10% of pharmacy needs which drive up overall Rx spend by +80% or more?

Blue Cross Explains Why Health Insurance Costs So Much

Blue Cross identifies three factors driving rising heath insurance costs:

Chronic disease
Prescription drugs
Unhealthy lifestyles

Texas School District Fires TRS ActiveCare But Keeps Blue Cross

Chasing nickels and dimes instead of dollars is never a good idea……………..

The Insidious Medical Trend Monster

“Medical trend” means medical inflation. It’s not driven by free market economics. Rather it’s journey to your health insurance renewal is spawned through managed care contracts you can’t see nor audit.

A Plan Sponsor’s Ultimate Cost Containment Strategy That Works Every Time

“Molly, Wait Until You Hear About This………………….!”

I bet you’re facing a health insurance rate increase again. Just a feeling I have founded on experience. My gut is never wrong. And, it’s a double digit increase for heavens sake.

Brownsville Texas Named The Unhealthiest City In America

Article Referred By Rusty Rusteberg

The Blue Cross representative for the second largest employer south of San Antonio has another gem to add to his renewal presentation. The Brownsville Independent School District (BISD) health insurance premiums are some of the highest among school districts across the state. Now he has another explanation why health care costs are going up again. “It’s all your fault your rates are rising again! You’re the unhealthiest population in the USA, the planet even!”

How Direct Primary Care Can Revolutionize Health Care

THE PODCAST BY KEVINMD

Subscribe to The Podcast by KevinMD. Catch up on old episodes!

The U.S. health care system ranks poorly among high-income countries, but the direct primary care (DPC) model offers a potential solution. In this model, primary care providers are paid a consistent fee through a retainer or membership program, rather than relying on insurance billing. This frees up providers to spend more time with patients and offer comprehensive care. Both patients and providers in the DPC model report high levels of satisfaction and there is evidence of decreased utilization of expensive services and lower overall health care costs. Join us as we speak with Dr. Sara Pastoor about the potential for the DPC model to improve primary care and the health care system in the U.S.

Texas Seizes Insurer – One Of The Largest Health Insurance Failures Ever

Texas regulators seize and liquidate Friday Health

“It will be one of the largest health insurance failures ever. After almost $300 million in losses in just three years and ending with a quarter-billion-dollar liability, the Texas Department of Insurance moved to liquidate Friday Health Plans’ Texas subsidiary.”

The ‘King Kong’ of Weight-Loss Drugs Is Coming

“I Can Eat Whatever I Want Because I’m On Mounjaro!”

People who are overweight are flocking to the drug Ozempic to slim down. Looming is an even more powerful weight-loss treatment.

Joe Wilson’s Frontier DPC Presentation To 7,200 Member School District

Boosting Virtual Care Adoption, Health Equity in Rural Areas

Rural Americans face a wide array of healthcare issues. Not only are they more likely than their urban counterparts to die of chronic conditions like heart disease, cancer, and stroke, but they also have higher rates of obesity and diabetes, according to the National Institutes of Health.

New Legislation Aims to Widen First-Dollar Telehealth Coverage

A group of six US representatives and senators introduced bipartisan legislation to extend access to telehealth by eliminating the deductible requirement for those with Health Savings Accounts.

Bye Bye PBM Spread Pricing

PBM drug pricing transparency reform bill headed to the full Senate

The bipartisan pharmacy benefit manager bill, which was approved by a Senate committee, would make it illegal to charge health plans and payers more for a prescription drug than what PBMs reimburse to the pharmacy.

Indiana Hospital Care Highest In The USA?

Indiana hospital care: Employers and workers paid $2 billion above the national average

New analysis shows that $1.6 billion would have come from 30 non-profit hospitals – and employer groups are now urging state lawmakers to take legislative action.

Direct Primary Care Is Virtual Care With A Sprinkle of Brick & Mortar Added In

No matter how you slice it, today’s version of Direct Primary Care (PCP) is Virtual Primary Care with a little bit of Brick & Mortar added in.

PBMs Are Modern Gangsters

“PBMs are modern gangsters,” Yost said in a statement. “They were designed to protect and negotiate on behalf of employers and consumers after Big Pharma was criticized for overpricing medications, but instead they have absolutely destroyed transparency, scheming in the shadows to control drug prices on all sides of the market………………….

The Case For Paying Primary Care More Than Specialists

“It used to be that the best and the brightest went into primary care because it was the most challenging……………..I don’t mean because you have to see a patient every five minutes. I mean that every time a patient walks through the door, you don’t know what’s going to come at you, and you have to be prepared for anything.”

Covenant HealthCare “Allegedly” Did Something Bad & Horrible

Covenant HealthCare, two physicians to pay $69M in false claims settlement

Hayley DeSilva – Wednesday, March 29th, 2023

Saginaw, Mich.-based Covenant HealthCare and two physicians have paid $69 million in three civil settlements for allegedly violating the False Claims Act, the Justice Department reported March 29.

Thinking Outside The Box

How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them

by Patrick Rucker, Maya Miller and David ArmstrongMarch 25, 5 a.m. EDT

Internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. “We literally click and submit,” one former company doctor said.

How Much Would Your Plan Pay For These Claims?

“What would your plan have paid for these claims?” asked the plan sponsor shopping for competitive alternatives.

How Much “Juice” Can You Squeeze From A Patient?

Answer: Not enough

School District’s Health Insurance Up 245% But They Get A Hell of A Deal on Fixed Costs?

Is Blue Cross paying ECISD for the privilege of being their TPA?

Today’s Pop Quiz

Which is the easier sale in today’s health insurance brokerage market?

A Common Sense Health Plan That’s So Good It’s Hard To Sell

Have you ever tried selling something that’s so good it doesn’t sell? “It’s too good to be true!” says the prospect. “If it were as good as it is, everyone would be buying it. Since no one I know is, it must not be as good as you’ve proven it is!

Texas Hospital Association Cries A River

SOURCE: Darren Fogarty – Associate Director, Purchaser Value at PBGH

5 days ago, the Texas Hospital Association issued a “fact” sheet that lies by omission in citing $3.2 billion in losses for Texas hospitals with nary a mention of where those losses came from.

Pfizer and Moderna Enter “Price Gouging” Phase?

Psssst! Godfather, Michael Says We Need To Get Into Pharmaceuticals!

For the two calendar years covering the roll-out of its toxic C19 mRNA injections, Moderna had sales of 37.5 billion bucks that cost it 8.6 billion bucks to make – leaving gross margin of around 29 billion bucks.

Specialty Drug Cost Containment Strategy – The Indian Giver Method

Why would any payer cover something when they have only the slightest intention of doing so?

Texas SB 1296 – Bureaucrats Have Information You Will Never See

Have you ever been told as a kid you couldn’t have something?

Texas Legislature Moves to Discontinue Work Comp Group Self-Insurance

Texas lawmakers proposed a bill that would discontinue group self-insurance and dissolve the Texas Self Insurance Group Guaranty Fund and Trust Fund. Identical companion measures HB 4859 and SB 2269 would prohibit the commissioner from issuing a certification of approval to a proposed self-insurance group on or after Sept. 1.

Continue reading Texas Legislature Moves to Discontinue Work Comp Group Self-Insurance

BUCA Bucks vs MedSave Bucks

Every self-funded plan maintains a money pot to pay claims as they occur. Monies leaving the pot are often paid in BUCA Bucks.

Monster Texas School District Gets An “F” In Health Care Finance

The second largest employer group south of San Antonio tackles rising health insurance costs the old fashion way………………..

Drug Dealer Advertises “Everyday Low Price of $389,106”

There’s not too many plan sponsors that can afford a plan member’s $389,106.02 drug habit. It only takes a few specialty drugs like this to bankrupt a group medical plan.

Insurance To Credit Cash Pay Patients Under Proposed Texas Legislation

If proposed HB 2002 passes the Texas legislature this session, “An insurer shall credit towards the insured’s deductible and annual maximum out-of-pocket expenses an amount the insured pays directly to any physician or health care provider for a covered medical or health care service or supply if a claim for the service or supply is not submitted to the insurer”.

Texas Legislature Eyes Primary Care Expansion Through FQHC’s

A bill has been introduced in the Texas legislature intended to expand primary care health services to employees of participating employers…………….

Why Employers Change Insurance Brokers and Benefits Consultants

EMPLOYER GUARD DOG vs CARRIER LAP DOG?

A Common Sense Health Plan Option You’ve Never Heard Of………..

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

Billed Charge = $17,462.66, Cash Price = $449

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………………..

PBMs Under Attack In Congress

Setting Aside Reserves

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.

BUCA Brokerage Monopoly Tough To Beat

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

It’s Coming! States Eye Hospital Price Controls As Best Health Care Fix

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

Another Golden Nugget From The Godfather of IRC 501r

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.

Nurse Navigators Rock!

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.

Interlocal Purchasing Cooperative

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.

Indiana’s Hospital Systems Stand Committed to Affordability

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

A Rx Business Strategy That’s Guaranteed To Produce Huge Profits

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.

New Age Captive Opportunity

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.

Ohio Firm Saves $37,000,000 In Medical Bills

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.

Millennials’ Take On Health Care

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.

Oh Oh, What Do We Do Now!

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……………….

The Upside Down Hospital

Description	Associated Codes	Gross Charge	Payer Allowed Amount	Cash Discount Price	Deidentified Min Allowed	DeIdentified Max Allowed
Description	Associated Codes	Gross Charge	Payer Allowed Amount	Cash Discount Price	Deidentified Min Allowed	DeIdentified Max Allowed
Bypass Graft Of Blocked Heart Artery	231-236	$122,450.30	$47,573.58	$85,715.21	$21,431.63	$62,562.13
Bypass Graft Of Blocked Heart Artery	231-236	$122,450.30	$32,572.65	$85,715.21	$21,431.63	$62,562.13

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 vs Cash Pay for Health Care?

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

Pratter Logic

Earning <$58,320 = Free Health Care

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.

Texas Legislature Ends Hospital Bullshit

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

No Gag Rule Opens Doors For Inquisitive Minds

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.

New Rx Cost Driver – Off Label Drug Treatment for Obesity

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………..

North Korea Unveils New Wellness Program

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

American Health Care Has A Moral Problem

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 Wins Houston Rodeo’s “Mutton Bustin” Contest – Qualifies For Final Championship Event

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

Buyer’s Remorse In Contract Disputes

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

Let’s Go Shopping………….For Health Care

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

Is American Hospital Billing The Biggest Scam Today?

“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”