Texas HB 1534

HB 1534 is due for a vote today at 1:00 pm CST. The Texas Medical Association is for it, TPA’s and self-funded employer plans are against it.

HB1534

Editor’s Note: The following was received from a San Antonio physician:

Bill, Sorry, but I’m not on board on this one.  There are too many instances where TPA’s/MCO’s/Networks sell my discounts (if I give any) to others without my consent.  If I give a discount to a particular network in exchange for access to a certain number of patients, I don’t expect them to ‘sell’, lend, lease, or whatever to a smaller NW or TPA that I otherwise would not have given a discount to.  And it’s all been going on without my knowledge or consent.  It’s happening all over the place in managed care contracts and workers’ comp contracts as well.  The discount I offer to a particular NW, TPA or whomever, is between them and me, no one else, unless I consent to it.  Any other sales of this information should be disclosed to me, and if they want to do that, then I should share in the money they’re making on this.

You can pass this to your friends in the industry.  There are two sides to this stuff.

So. Texas Insurance Broker Sentenced to Prison

HARLINGEN — A Harlingen insurance broker has been sentenced to three years in federal prison for his role in a scheme to sell nonexistent windstorm policies to Valley Baptist Health System. Prosecutors said Michael N. Swetnam Jr., 47, helped to defraud VBHS out of more than $3.8 million by selling nonexistent and altered insurance policies.

Continue reading So. Texas Insurance Broker Sentenced to Prison

PRIMA Names Texas School Official Risk Manager of the Year

James E. Huckaby has been named Public Risk Manager of the Year by the Public Risk Management Assn. Mr. Huckaby is director of risk management of the Mesquite Independent School District in Mesquite, Texas, a post he has held 17 years.

Arlington Va.,-based PRIMA gives the award annually to public risk managers who demonstrate innovation and commitment to the field.

Mr. Huckaby manages the school district’s property/casualty insurance program, employee benefits, loss-control efforts, workers compensation program administration, and federal environmental compliance. Workers comp, auto liability

He is credited in reducing the school district’s workers comp and automobile liability claim costs by 60% and 45%, respectively.

Mr. Huckaby accepted the honor at an awards luncheon Monday at PRIMA’s 32nd Annual Conference in Portland, Ore. “I stand here today because of the numerous professional opportunities made available by PRIMA,” Mr. Huckaby said.

Posted On: Jun. 07, 2011 9:44 AM CENTRAL Mike Tsikoudakis PORTLAND, Ore.—

Patients In Arrears Face Collectors

 
Patient debt is big business. Purchase debt for pennies, collect dimes, nickles and dollars from medical debt deadbeats.  We know of a dynamic person from the Lower Rio Grande Valley, who while at UT Pan AM, did a research paper on medical debt collection. He developed a business model that has made him millions of dollars. He approached a local hospital, offered to collect uncollectible debt for 25% of the take if the hospital would give him free office space and a telephone. That was 30 years ago. He now employs over 700 employees.

 Continue reading Patients In Arrears Face Collectors

CanadaRx – Self Funded Plan Option? Is It Legal?

 

 
 
 
 
 
 

This advertisement (CanadaDrugs.com) is in the June 2011 issue of Texas Co-op Power  – Guadalupe Valley Electric Co-op. Importation of foreign Rx does not seem to be an issue apparently. This could be a heck of a mail order source for self-funded health plans if it is legal.
Any comments you have, or information that would be helpful here, please let me know. PBM’s- what do you think of the pricing in this advertisement? Consultants – have you checked out the legality of importing Rx for ERISA plans?

 

 

Continue reading CanadaRx – Self Funded Plan Option? Is It Legal?

Memorial Day 2011

Lt. Col. Rusteberg, May 1944, London

West Point 1934

Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.

The President of the United States of America, authorized by Act of Congress July 9, 1918, takes pleasure in presenting the Silver Star to Lieutenant Colonel (Infantry) Edwin Rusteberg (ASN: 0-19542), United States Army, for gallantry in action while serving with Headquarters, 1st Battalion, 242d Infantry Regiment, 42d Infantry Division, in action on 9 January 1945 at Hatten, France. As Commanding Officer of the First Battalion, 242d Infantry Regiment, during the action at Hatten, France, Colonel Rusteberg planned and executed the defense of that area with outstanding success. In spite of point blank fire from enemy tanks supported by Infantry that raked his positions with fire, Colonel Rusteberg by personal example held his troops in position and withstood the enemy attack. Fighting side by side with his men in the face of overwhelming odds without mechanized or artillery support, Colonel Rusteberg by his courageous leadership, tenacity and devotion to duty played a major role in the successful defense of the town of Hatten.

General Orders: Headquarters, 42d Infantry Division, General Orders No. 131 (1945)

Action Date: 9-Jan-45 Service: Army Rank: Lieutenant Colonel Company: Headquarters Battalion: 1st Battalion Regiment: 242d Infantry Regiment Division: 42d Infantry Division

Blue Cross Accused of Price Fixing – Favored Nation Clause

Blue Cross is accused of price fixing in a lawsuit filed last year. Could it be that Blue Cross agreed to hospital pricing demands, with the understanding that the hospitals would charge other PPO’s more?

Did the negotiating process look something like this “Ok, we will pay you those high whorehouse prices you demand, but you must agree to charge our competitiors more!”

Continue reading Blue Cross Accused of Price Fixing – Favored Nation Clause

$295 MRI Includes Reading

Most insureds have no idea what their insurance plan pays for an MRI. And they really don’t care since “insurance pays the bills.”

But they should care. After all, their premium rates are directly proportional to medical care costs. Insurance companies are simply conduits for health care revenue flows, taking their cut as money cascades  it’s way through the health care system honey pot.

Insurance companies are not the only ones with a vested financial interest in health care costs. Many intermediaries participate in the cash cow we call the American Health Care System. Brokers of all sorts earn high fees. Some medical providers have partnership agreements with these brokers and participate in revenue streams.

Ever heard of an MRI broker? They exist. Their sales pitch is something like this: “Our services are free! Just call our toll free number and we will find the best and lowest cost MRI for your employees, as needed. We will even set the appointment! While the average MRI charge in your area is a whopping $2,500 after the PPO discount, we have been able to get the same MRI in the same area for as low as $900! And you pay us nothing – we participate in the $900 “discounted” price and the MRI center pays us!”

And, some doctors refer patients to MRI centers that pay the doctor a “kickback.” Unfortunately, in some localities, this is very common practice.

The MRI business model, as practiced by most, is extremely lucrative for many participants. Very lucrative.

Now enters RPN of California. Their MRI business model is based upon the novel concept of connecting the payer directly with the provider and eliminating all the middle men. For $295 per MRI, this company makes a nice profit, and the payer saves money. Keep your eye on RPN. You will hear more about them in San Antonio, Texas.

Why San Antonio? A market analysis shows 37 MRI locations and their average costs: http://www.newchoicehealth.com/Directory/CityProcedureType/Texas/San%20Antonio/15/MRI . Statistics show that there are 91.2 MRI’s per 1,000 population. Based on this statistic, there are approximately 192,000 MRI’s performed annual in the San Antonio area, or 524 MRI’s per day.

For more information on RPN, visit www.rpnofcalifornia.com

Editor’s Note: See similar posting – http://blog.riskmanagers.us/?p=5864 Health care professionals like RPN bring competition to the health care marketplace. That is good for consumers.

“Once we rid ourselves of traditional thinking we can get on with creating the future”

– James Bertrand

 

The Whole Tooth Blogtalkradio

Tue, May 17, 2011 3:08:21 PM
My first interview 5.17.11
From:
Darrell <darrelldk@tx.rr.com>

View Contact
To: Darrell <darrelldk@tx.rr.com>  

I’m preparing for my first interview. It is scheduled to take place on Tuesday, May 31, at 7PM Fort Worth time on The Whole Tooth Blogtalkradio.

Continue reading The Whole Tooth Blogtalkradio

“Gag-Clauses” In PPO Contracts Challenged

CALIFORNIA: The 2011 version of a hospital transparency bill was unanimously voted out of the Senate Health Committee last week. The legislation would prohibit hospitals from including provisions, commonly referred to as “gag-clauses,” in contracts with health insurers.

These provisions prevent disclosure of hospital cost and quality information to health plan members. Individual hospital systems, the UC System and the California Hospital Association continue to oppose the bill, while insurers, payers and labor unions support the measure.

Editor’s Note: Texas is doing the same – http://blog.riskmanagers.us/?p=5451

Feds And Amarillo Health Care Providers Settle Price Fixing Charges

An association representing 900 physicians in the Amarillo area has agreed to a Federal Trade Commission order barring it from jointly negotiating the prices it charges insurance providers, according to a news release.

The FTC alleged in a complaint filed with the order that Southwest Health Alliances, Inc. and BSA Provider Network, a division of Baptist St. Anthony’s Health System, has violated federal law since 2000 by fixing the prices its member doctors would charge insurers.  This led to higher prices for consumers and businesses.

Continue reading Feds And Amarillo Health Care Providers Settle Price Fixing Charges

Rio Grande Valley Mobile CT Scanning Company Takes Service to Customers

Valley Business Report May 2011

A Rio Grande Valley company has launched the first mobile CT scanner service south of Dallas. Manuel Figueroa and Orlando Rivera, Registered Radiologic Technologists launched their business after working on the concept for over a year.

Medical insurance payers can save up to 75% off their CT Scan costs.

For more information, contact Mobile CT Imaging at 956-230-0109.

Editor’s Note: Self funded medical plans in the Valley, such as the Brownsville Independent School District, should look into a direct contract with these two Valley businessmen.  CT costs could be drastically reduced while still maintaing quality care.

MultiPlan Denies Guilt – California Lawsuit Has National Implications

NEW YORK, NY–(Marketwire – 04/14/11) – MultiPlan, Inc. was been named as a defendant in a lawsuit brought over a year ago against Sutter hospitals alleging false billing of certain anesthesia services. California Insurance Commissioner Dave Jones recently intervened in the lawsuit, and issued a press release announcing that action.

Continue reading MultiPlan Denies Guilt – California Lawsuit Has National Implications

Seven Week Wait to See A Doctor? Is This The Future of Health Care?

 

The United States faces a physician shortage. In Massachusettes, where almost all residents have health insurance, patients must wait as long as seven weeks to see a primary care physician. And, many physicians are either not taking on new patients, or are not accepting Medicaid or low income patients due to low medical reimbursements.

Continue reading Seven Week Wait to See A Doctor? Is This The Future of Health Care?

Firms Unbundle TPA Services – Uncomfortable With Markups Charged By TPA’s

“……..A few years ago, however, he changed TPAs to eliminate hidden charges and gain direct interaction with the managed care company with which his undisclosed TPA contracts.”……………”For example, he now pays a flat amount per bill for fee schedule bill reviews, rather than paying on a percentage-of-savings basis.

“The fees per bill were just outrageous compared to what I am paying today,” Mr. Tilley said……………….”

Continue reading Firms Unbundle TPA Services – Uncomfortable With Markups Charged By TPA’s

California VS Multiplan

Subject: Califoria Legal Action

Hey Guys, I wondered if you guys ( bloggers supreme ) had seen this case out of California ? Started as an action by an audit firm against Sutter Health and then the California Department jumped in. The interesting detail to me is how PHCS / MultiPlan is being treated as an “ accomplice “ due to the onerous terms of the PPO agreement ( i.e. no audit , no review ).

My opinion is that this case could be huge if it gets legs and other Departments across the country pick up on the logic. While this case is specifically applied to the anesthesia sleight of hand , could the same rationale not be applied to other areas ? How much abusive billing is covered over by the handcuffs placed on plans via PPO contract terms ? Arguably, the entire chargemaster process is driven by the incentive of “ percentage off “. Bill more get more.

CA v Multiplan  (FOR A QUICK REVIEW, READ PAGES 12-18)

Texas Political Subdivisions and Insurance Consultants

  

Dual Compensation – Hide & Seek

Many Texas political subdivisions employ licensed fee based insurance consultants to assist in the competitive procurement of insurance and on-going risk management advice. The Texas Department of Insurance issues two licenses required to act as a fee based insurance consultant in this state.

Continue reading Texas Political Subdivisions and Insurance Consultants

HB 1534 – TPA’s Can’t Comply Because PPO Networks Won’t Disclose

This is an URGENT email we received this morning:

We apologize for the late notice but we just received notice that the Texas House of Representatives Insurance Committee is meeting today starting at 1:00 and they will be voting on HB 1534. This is a bill that is aimed at the “Silent PPO” issue but has some unintended consequences that are bad for our industry.

Continue reading HB 1534 – TPA’s Can’t Comply Because PPO Networks Won’t Disclose

AMPS Introduces PEPM With Guaranteed ROI & Payer Indemnification

The Cost Plus Revolution in Texas has saved self-funded employer sponsored health plans millions of dollars (See previous postings by typing in “Cost Plus” in the search box on this page).  More Plan Sponsors are realizing that PPO discounts based off inflated medical bills through contracts that they cannot see confounds  their fiduciary duties.

Amps (www.advancedpricing.com) works with self-funded health plans. Their proven track record shows significant plan savings for their clients.

Continue reading AMPS Introduces PEPM With Guaranteed ROI & Payer Indemnification

Texas SB 1686 – Wrongfully Convicted Individuals Entitled to Group Health Insurance

“A person entitled to compensation is also entitled to group health insurance from the county in which the offense that was the subject of the wrongful conviction occurred as if the person were an employee of the county.”

http://www.legis.state.tx.us/tlodocs/82R/billtext/pdf/SB01686I.pdf#navpanes=0

Editor’s Note: If this bill passes, Texas counties may need to re-evaluate their GASB 45 liabilities.

Sixth Circuit Lifts Injunction Requiring Blue Cross to Disclose Discount Information

MyHealthGuide Source: John Eggertsen, Esq., Eggertsen Consulting, P.C., www.jhelaw.com

The U.S. Court of Appeals for the Sixth Circuit April 6 reversed an injunction that required Blue Cross Blue Shield of Michigan (BCBSM) to provide a multiemployer health fund with documents detailing BCBSM’s discount arrangements with medical providers (Pipefitters Local 636 Insurance Fund v. Blue Cross & Blue Shield of Michigan, 6th Cir., No. 09-2294, unpublished 4/6/11).

Continue reading Sixth Circuit Lifts Injunction Requiring Blue Cross to Disclose Discount Information

North Carolina Insurance Exchange – Secrecy Shrouds Contracts

North Carolina House Bill 115, legislation written by the insurance companies, would create a health benefits exchange that is neither accessible nor transparent. Remember the North Carolina State Health Plan fight? For those who need a refresher, North Carolina signed a no bid contract with Blue Cross to manage the State Health Plan. The contract was secret, not even legislators could get a copy until public pressure forced it into the open.

Continue reading North Carolina Insurance Exchange – Secrecy Shrouds Contracts

Analyzing DOL’s Review of Self Funding

On March 30, 2011, The U.S. Department of Labor issued its long-awaited report on self-insured health plans as required by the Patient Protection of Affordable Care Act.  The report focuses on self-insured group health plans – what type of employer self-insures; whether self-funded plans are financially solvent; the purpose and effectiveness of 5500 forms; the role of stop-loss; and, do self-insured group health plans truly offer less costly coverage.   The bottom line?  Continue reading Analyzing DOL’s Review of Self Funding

Federal Insurance (Welfare) Program Covers (Mandates) Pre-Existing Conditions

The federal agency Centers For Medicare & Medicaid Services is hoping to boost enrollment in a public insurance program  (welfare program) for U.S. residents who have been denied private health insurance because of pre-existing illness or disability.

In Texas, less than 1,200 have joined the new plan. Texans must be a damn healthy group of people.

Continue reading Federal Insurance (Welfare) Program Covers (Mandates) Pre-Existing Conditions

US Supreme Court To Weigh Expedited Review Of Health Reform Case

The U.S. Supreme Court on April 15 will convene a private conference to consider an appeal by Virginia Attorney General Ken Cuccinelli (R) for an expedited review of a federal judge’s ruling in the state’s lawsuit against the federal health reform law, CQ HealthBeat reports (Norman, CQ HealthBeat, 3/23).

Continue reading US Supreme Court To Weigh Expedited Review Of Health Reform Case

The Only Thing A PPO Can Guarantee Is No Balance Billing

The Phia Group, LLC
March 22, 2011

Balance Billing… it happens. With health care reform in effect and costs of providing benefits soaring, our industry has become increasingly careful with their claims dollars. Plan Administrators, seeking to cut costs and enforce their plan documents, are combating provider overcharges with a new vigor.

Continue reading The Only Thing A PPO Can Guarantee Is No Balance Billing

In Texas Two Insurers Account For 60% of Insureds

Rather than moving  toward a competitive world, we seem to be moving toward the opposite extreme: monopoly. Major consolidation is underway both on the provider and insurer sides of the market. And while this trend was already underway before Barack Obama became president, without doubt it is accelerating because of ObamaCare.

The graph below shows what things look like in the market for commercial insurance in major Texas cities:

Blue Cross already has 70% of the market in three of the nine largest metropolitan areas. In all of them, and for the state as a whole, more than 60% of all customers buy from only two insurers.

Is Common Sense Missing In Employee Health Plans?

Financing and administering health care through a self-funded employee welfare plan takes many forms. Financing is accomplished through mix of employee and employer contributions – determining the money value of the plan, current and projected is easy. Determining the actual value is not as easy. Determining who shares in the money sometimes takes a path of convoluted twists and turns.

Continue reading Is Common Sense Missing In Employee Health Plans?