Risk Managers

http://www.taxfoundation.org/publications/show/24997.html

Molly Mulebrier returned today from a secret undercover assignment and is being debriefed by our staff. Contrary to published reports, Ms. Mulbrier was not on assignment to the Congo and was not banished from this blog – that was a brilliant ruse initiated by the editorial staff here to throw off private investigators and insurance brokers seeking the Brownsville Independent School health insurance contract.

Although our debriefing is not complete at this time, we are encouraged at the amount of factual information our investigative reporter has obtained. Actuarial data dating back to 1999 has surfaced, for the first time. This is a significant discovery with tremendous implications to the integrety of the request for proposal process.

As location, location, location applies to real estate, data, data, data applies to underwriting a competitive group health insurance program. He who has data wins, he who has good data wins a lot, and he who has real time data wins all the time.

We expect Mulebrier’s debriefing to continue over the weekend. Our team of private investigators have sworn an oath of secrecy until all information can be confirmed by Don Pedro and his editorial staff.

Recently, at a Special Called School Board Meeting, a member of the school board asked their insurance consultant if he was to receive any fees whatsoever from any source other than the fee paid to him by the district. His response was:

“Just as background, just so’s you’ll know, about ah oh early mid 90’s there was a great deal of concern in the insurance industry about whether or not an individual’s licensed as an agent or licensed as a consultant. So working with the State Insurance Board, we came up with license a requirement for health insurance counselor specifically (to health insurance)   I worked with the State Board of Insurance in developing that program and approached them also with the requirements of that process because we were having a great deal of trouble with consultants that were getting paid *********.   I work very closely with the Department of Insurance ******* fraud to help resolve those things that occurred throughout the state *******   That can be confirmed very easily.   *******”

So, we tried to confirm this.

Here are the Facts:

Texas Department of Insurance has been issuing Life & Health Couselor License since the 1980’s. The consultant stated that he worked with TDI in the 1990’s to develop the license. He was granted a Life & Health Counselor license on 8-21-2002.

We report, you decide.

Editor’s Note: The transcript above was from a tape of the meeting obtained by our staff this morning. The redacted parts of the transcript were parts of the tape that were overridden by exclamations of disbelief of the person taping the meeting. Excerpts of the redacted parts went something like this: Damn, I cant believe he said that!

A careful review of the entire tape reveals disturbing contridictions which we will not get into here. We believe a more formal setting for review and discussion is appropriate.

 

 

Today I witnessed an extraordinary meeting wherein a deep South Texas public school district, employing over 7,000 teachers and support staff, awarded a $38,000,000+ group health insurance contract to a new vendor recommended by a paid insurance consultant.

Being in the insurance industry for almost 40 years, I had a distinct advantage over most of the spectators who attended since I know the business and understand the semantics. What I heard at the meeting concerns me deeply, especially as a taxpayer of the Brownsville Independent School District.

The BISD fired the current claim administrator to “save money.” That is nonsense. A claim administrator does not save money for a client, they simply process claims.

If, as explained, the BISD claims went up last year, was it determined why? Not from what I heard listening to the paid insurance “expert.” All I heard was that a “claim re-pricing” exercise was employed.  A claim re-pricing exercise does not work, and I can prove it.

None of what I heard at this meeting adds up. I have a lot of unaswered questions. There must be more to this mystery.

Arnulfo “Half Pregnant, Half Guilty” Olivarez, whose sentencing was set for this coming Friday, will now have his day in court in time for the Thanksgiving holidays. The sentencing is set for 9:30 am on November 24.

This is at least the fifth time Half Guilty, Half Pregnant Olivarez has had his sentencing delayed. Could it be that the Feds want to keep him “on ice” for possible future indictments of fellow consipirators and then a plea deal in return for cooperation brokered with the Judge?

The Brownsville Independent School District will be meeting tomorrow to award third party administration services for their self-funded health insurance plan. The current TPA is HealthSmart which has everything to lose and nothing to gain from the BISD request for proposal process.

Rising medical costs to the school district is the driving factor to change TPA’s it seems. But that makes no sense at all since a TPA simply administers claims and have nothing at all to do with setting medical provider reimbursements. Could the proposed change have anything to do with a new Board of Trustees elected last fall?

If the BISD is concerned about rising medical cost, they should directly negotiate with area hospitals and doctors as did the Tyler Independent School District four years ago. Their costs dropped over 40% the first year, and Tyler has not had to reduce benefits or increase plan funding since.

http://m.brownsvilleherald.com/brownsville/db_15631/contentdetail.htm?contentguid=cFLcNwSU&src=cat

Ever wonder what motivates your insurance consultant? Is he or she really looking out for your best interests or are there underlying motives at play?  Finally, a new device just released will help you to uncover hidden agendas and ulterior motives that may be affecting your bottom line.

Included with your order will be sample questions that experts say will uncover the darkest and deepest secrets of most fee based insurance consultants. A sample includes “Have you been promised addtional business from a vendor prior to the award of the contract?”, “Have you given our current insurance company the same opportunities that you have given the vendor that you are recommending?”, “Have you blackballed any interested vendor from competing for our business?”  “Who really did this analysis – you or the vendor you are recommending?”

We are excited about this new technology and intend to try it out soon.  If you have a test case for us, we would be happy to lend you our Truth Detector at no charge for the month of August.

You may order your very own truth detector from this website – supplies are limited so order today.

 

Enhanced Truth Detector Available for $99.95

Ever have to change TPA’s but you are not sure if the one that looks the best is really the best?  A name change three times in four years could be a red flag. An array of equity partners coming and going may cause a slight nerve twitch or tingling down your leg – maybe an inner physical warning signal that maybe things are not just quite right. Or, how about a major move from one location to another for no apparent reason? Perhaps TPA’s are nomadic by nature one could surmise. Or, is there a red flag if you find out that scores of key employees with tenure are leaving with many of the remaining sending out resumes…..and going on job interviews while out and about? How about a combination of all of these signals? Would that be a Red Flag to you?

Finally, we are going to put to rest the question that has plagued many political subdivisions in deep South Texas – Who Has the Best PPO Discounts Bar None?  A rare and unique opportunity has surfaced, exploitation of which is paramount to opening Pandora’s Box and finding a bottle with a genie in it. Only, this time the genie has more than just three wishes to grant. Mental giants have been invited to join the fun, with the promise of exposing potential solutions to the Gordian Knot of the merky and mysterious world of PPO discounts. It does not get better than this. Stay tuned Wishbone. 

                                                                                

Meritain may be making a move to acquire blocks of self-funded business in Texas. Rumors are rampant but unproven – http://www.meritain.com/. Cash flow problems may exaserbate the dimensions of terms of purchase to the possible advantage of the buyer. This news, along with the Viant – Multiplan Merger announced today – viant-merger may be just the beginning of some major market shifts in anticipation of Washington’s effort to implement some sort of national health plan for all Americans.

Insurgent Molley Mulebrier posted this without permission of this Blog Master. Some of these independent journalists are ballsy to the point of being annoying. We apologize to our readers. Effective Monday Ms. Mulebrier will be sent on assignment to The Congo for an extended field trip to report on the African Mud Fly and It’s Impact on Global Warming.

First it was Arnulfo “Half Guilty, Half Pregnant” Oliverez indicted for bribery of public officials to gain lucrative insurance contracts. Then it was Edcouch insurance agent Aaron Gonzalez  who plead guilty to a similar offense. Now it is two more insurance agents from Harlingen who are accused of selling non-existent insurance policies to Valley Baptist Medical Center.  We suppose that what makes these individuals different is that they got caught. Of course, one is guiltyonly when a confession is brokered or a jury decides their guilt.  http://www.tdi.state.tx.us/fraud/frpress.html   

                                     

Arnulfo C.  “Half Pregnant” Olivarez, admitted felon, is to be sentenced in Federal Court in McAllen at 9:00 am August 14, 2009 for his crimes. At his August 2008 court appearance before Federal Judge Hinojosa, Oliverez plead guilty of charges against him but stated that he was really only half guilty. (See previous postings on this blog).

Justice, it would seem would require a prison sentence – however with the Texas Department of Insurance renewing his insurance licenses recently, it would appear some sort of deal was made in exchange for leniency.

With the United States moving towards some sort of national health care plan, a careful study of health care economics and opportunities in other countries with socialized medicine in play may provide health insurance agents and third party administrators with clues as to their future role in the health care delivery system.

A Canadian TPA touts their Cost-Plus Tax Free Health Plan for Canadian citizens: www.costplus.ca

 

 

The Grass is Greener on the Other Side of The Fence – The Age of the Golden Goose

In the early 1980’s, group health insurance rates began to skyrocket. Medicare and Medicaid, signed into law by President Johnson in 1964, was beginning to have an unintended financial impact on the health care delivery system. Cost shifting to private pay plans began, health insurance rates began to climb. to new highs.  Insurance companies embraced a new concept called “Managed Care”. PPO’s and HMO’s fought for market share.

As medical insurace premiums rose, insurance companies realized tremendous and lucrative cash flow opportunities. If an insurance company could make 2% on the float, it would mean millions, if not billions of dollars in profits. More insurance companies entered the health insurance market. Prudential and Aetna for example, redirected their profits by entering, for the first time, the health insurance market. And, more insurance agents, especially property & casualty agents, joined in the feeding frenzy seeking 15% commission on health insurance sales.

There was never a better time to become an independent health insurance broker. The sky was the limit, the market wildly free and unfettered, with unbelievable financial rewards for those that worked hard and long hours, day after day. Competition amongst insurance brokers was intense and fratricidal. Greed became a driving factor and honorable business ethics became uncommon.

After nine years working for a health insurance company, I stepped out into the brokerage world seeking my fortune. It would be an interesting learning experience, frought with dangers and rewards. I was entering  unchartered waters, complicated by the good old boy system of alliances and unspoken codes of  questionable ethics of underground operatives on the dole.  I was about to make more money per year than I ever dreamed of making. Although I was “just an insurance agent”, I was to make more money than the owners of the companies I help to insure. 

But, I was about to be hit with a seemingly unsurmountable roadblock.

Editor’s Note: This article was written by Molly Mulebrier of Dime Box, Texas. This is a fictional account of the experience of a health insurance agent.

“Money will buy anything” is the mantra of key political contributers in deep South Texas. And so it seems. “Hussein threw McAllen under the bus” has exaserbated local politics – will the defunct and nearly extinct Republican party of deep South Texas seize the initiative and make new polical allies with rich physicians and their political hacks?  Read all about it here – http://www.nytimes.com/2009/07/30/us/politics/30mcallen.html?_r=1&src=twt&twt=nytimes

http://www.snopes.com/medical/drugs/generic.asp

Office Visit for a total of $35 – heck of a deal when we are seeing office visits costing anywhere from $65-$190 through insurance programs. Dr. Posada publishes his prices and takes cash or credit card only. He does not accept insurance, nor Medicaid or Medicare. Cash only please! affordable-clinics.

If Brownsville Independent School District, Cameron County and the City of Brownsville would bid out for physician services rather than rely on boggus savings touted through PPO networks, the taxpayers would save millions of dollars a year.

In the late 1970’s, the company I worked for experienced an internal political shift in power. Politics are found in all organizations it seems. A new President was selected by the Board, and heads began to roll shortly thereafter. “New Blood” was needed in management, a new direction was charted and the ambitious new President had high expectations of increased market share.

The old and balding Senior Vice President of Sales was sacked. A new, young ex-car salesman from East Texas was selected to lead and command the troops towards a rolling conquest of the state, the goal of which was to increase market share from 23% to 25% within the year.

How to accomplish this? Easy, pay the sales force huge sales bonus based on net-gain in each territory, and “buy business.” That is when I realized I was sitting on a gold mine. I read the new sales incentive bonus program and realized right away that I did not have to even write a new group to get the bonuses; all I had to do was gerrymander my existing book of business. But, what really made my day was the new business rates we were getting from underwriting. We were buying business, no one could compete with our rates. We were giving the insurance away for pennies on the dollar. I became an order taker, a well paid order taker. My income rose to over six figures, and I was “made.” Customers were happy too, at least in the onset.

Eventually this strategy could not sustain itself and all hell broke loose. Member hospitals, all on an annuity contract with my company, began having cash flow problems due to slow (and incorrect) claim payment. Members were having difficulty getting their claims paid. No one was happy, and those of us in the sales division took the brunt of our customers anger every day. Instead of devoting time to selling new business, I was spending all my time as a roving customer service rep. Competition woke up and began making significant in-roads in the market. It was not fun.

Management decided that the sales force was paid too much money and the compensation formula was changed. A quick study showed that my six figure income would now drop down to where I was in the early 70’s. My customers were not happy, I was not happy.  It was time to move on.

Editor’s Note: This is a fictional character and is not intended to represent any one individual.

These websites publish the prices of procedures, which help when negotiating your medical bills:

www.healthbluebook.com, www.changehealthcare.com, www.outofpocket.com, www.myhealthscore.com

These websites offer bill-negotiation services:

www.myinsnet.com, www.medicalcostadvocate.com, www.billadvocates.com

Excellent article in Forbes, August 3, 2009 issue:  cut-your-doctor-bill

There is always a silver lining it seems. Perhaps the illegal drug trade is a good thing? A quick check at the Cameron County, Texas website under prison population, you can view pictures and the status of all 900+ inmates. Over 95% of the inmates are in for drug related offenses. With that many “druggies”, it would seem Cameron County could benefit from drug traffickers Robin Hood approach to neighborhood health care.

drug-gang-clinics

 Bruno, 1924-1938

Pet health insurance, thus far, has escaped the scrutiny of Washington’s Communist Cadres. There is no Pet Health Insurance Czar yet, not even a hint that one will be appointed anytime soon. So, what’s up with that?

Any history buff will tell you that the first pet insurance policy was written for a dog in Sweden in 1924. His name was Bruno. And in 1947 the first pet health policy was written in Britain with sales taking off rapidly. Today the UK has the most mature pet insurance market in the world, with over 18% of pets insured. Yet Jolly Old England has not extended their government safety net to man’s best friend. This is an obamanation indeed. Are not all of England’s four legged creatures entitled to health care?

And what about the USA? The first pet insurance policy sold in this country was to cover TV’s heroic dog Lassie. The underwriter, of course, was Lloyds of London of Great Britain. Today, pet health insurance in the United States is becoming popular with dog and cat lovers of all socio-economic levels.

Pet health insurance is a bargain these days. Premiums as low as $10 per month. And, you can take your animal to any licensed vet – PPO’s have not entered the scene yet. Group policies are available too. But, many Americans simply cannot afford coverage even at these rates. Yet, all American pets are entitled to health care, are they not?  We need and must demand that the federal government at least mandate better benefits, or implement a national pet health insurance plan at best. Animals have rights too!

And what about food insurance? When are we going to get that? We are all entitled to food, aren’t we?

Repealing the laws of supply and demand?

http://www.americanthinker.com/2009/07/welcome_to_mexico_gringos.html – This article is “right on.” We have been predicting this for the past six months and have even started a medical tourism company to assist our clients in seeking affordable and easy access medical care in expectation of when the communists (democrats) expand our national welfare state to include “free” medical care for all.

http://www.ibdeditorials.com/IBDArticles.aspx?id=332548165656854 – What else is in the 1,000+ page bill?

wsj-massachusetts-and-national-health-care

Editor’s Note: This is from Molly Mulebrier, Phd, CPA, CLU, Jd., of Dime Box, Texas, contributing editor for this Weblog. This is based on a fictional character and is the first of a four part series.

As I approach retirement, after being in the insurance industry since 1973, primarily in health insurance for employer groups, I believe it is time to come clean with the employers whom I have scammed all these years.  These confessions will surely pave the way for my safe passage through the pearly gates in lieu of the pergatory existance I truly deserve. Thank The Lord for the Forgiveness Doctrine which the Catholic church perfected many years ago.

It has been a fun ride with tremendous financial rewards. It has made me a millionaire several times over. And, I dont even have a college degree. A remarkable achievement it seems. But, it was only through deception, lying and cheating that I have been able to gain unreported riches at the expense of my clients. Bernie Madoff could have learned a lot from me.  He is in prison, I am not.

THE BEGINNING

My first job in the insurance industry was with a national health insurance company. I was a sales representative for them. I was assigned  a territory that included a substantial book of business which I quickly learned I could prey upon with abandon.  It was like being given a cookie jar with no adults in the room! With management’s active guidance and on-going and knowing approval, I became a sales star.

I quickly learned that when a renewal hit my desk, I could “override” the underwriter to my advantage. For example, if the renewal was for a political subdivision, I knew that any rate increase would trigger a Request for Bids scenario and my renewal would be known to all who attempted to bid and undercut my renewal. So, instead of the underwriter’s 15% renewal increase, I magically changed the renewal to a 32% increase, officially typed on a company letterhead. I was now in a win, win situation. I could not lose. My competition would come in 5% lower than my renewal, thinking they had a great bid. I would come in with a 23% increase and still have 8% in my pocket should negotiations with the employer become necessary. If I sold a higher rate increase than what the underwriter wanted, I became a darling of the underwriting department and future favors would come my way.  And, if I really wanted to make myself look good to management, and put more bonus money in my pocket at the same time, I would advise the group “Look, my renewal came in at 32% but I got it down to 23% . At this point, there is not much more I can do here. But, if you were to buy a $10,000 term life policy on each employee, I can drop the renewal increase down to 19% with the difference going to pay for the group term life plan. So, you are getting a “free” group life plan for all your employees”. And, I would add “we can do this since term life is a very profitable product line and we use those profits to offset health losses within our group health business portfolio.”

I first did this on a very large public school district. Not only did I pocket about $4,000 in bonus money, I won a trip to Las Vegas too! I was living the high life, earning over $50,000 per year on average in the early 1970’s. Better things were yet to come.

This is about a 2 minute interview:

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Money drives behaviour – wall-street-journal-insurance-consultants, wall-street-journal-revenue-streams

This White Paper is an excellent piece that all employers should read. It details the truth behind undisclosed consultant/agent/broker revenue streams.

unbiased-consultants – A MUST READ

This was written by Molly Mulebrier, Jd., Phd., CPA, CLU, of Dime Box, Texas. Her articles have appeared in Forbes, The Wall Street Journal, and the Austin Stateman. She has agreed to be a contributing editor of this weblog.

A 1,000 + page Health Care Bill passed committee this week. Here is a 4 page summary of the bill – http://www.stark.house.gov/images/stories/111/legislation/AAHCA/aahca-billsummary-071409.pdf.

Our office is in the process of reading the entire Bill. So far, it is much worse than what you see in the four page summary above. (The 4 page summary was put out by the government with a positive spin attached).

This Bill represents the biggest government power grab in the history of our country. And, once implemented, no one will like it, including those currently un-insured.

Below is a schematic of the Bill – this is not a joke:

jec20health20chart   

Plan on going to a particular hospital for surgery? Check out the hospital at www.hospitalcompare.hhs.gov.

Wanted: Someone to start my truck every morning and throughout the day as needed. Pay negotiable. Good benefits, attractive hours. Early retirement possible.

“It is no surprise that hospital profit margins are at an all time high since 1997” – ppos-gaming-the-system

Attn. Medical Providers – Maximizing Revenue, a must read – http://www.hcmarketplace.com/prod-2976/Managed-Care-Contracting-and-Reimbursement-Advisor.html

To review the 2009 Medical Fee Schedule, go to www.trailblazerhealth.com

Editor’s Note: Could this be the new fee schedule for our upcoming national health care plan? Since we now have two national health care plans, Medicaid and Medicare, would the new universal health care plan reimbursement rates be 1). Medicaid based, 2). Medicare based or 3). Hussein based? Or would existing PPO’s continue to play a role in our health care system? We suspect the correct answer is #3.

McAllen Independent School District – abbott-open-records-letter-ruling-or2004-10019-mcallen-isd

City of Lubbock – http://www.myfoxlubbock.com/dpp/news/local/061109covenant

“We seek to pay providers at market appropriate levels………….” And just what are market appropriate levels?

bcbs-ancell_responsive

highmark-provider-reimbursement-request

This picture was taken this morning on the way to Starbucks in Brownsville. The location is on the frontage road of Highway 77. According to the sign in the window, total charge for an office visit is $35 – cash or credit card only. No appointment necessary.

So the question is, if I have an insurance policy with a $20 office visit co-pay, do I go to this clinic and pay $35 or go to a PPO doctor down the street and only pay $20?  What is interesting is that the PPO network fee is probably a multiplier of 2008 RBRVS (Medicare), say 100% of Medicare for example. In that case, the PPO doctor down the street gets paid $80-$145 for the office visit, which the employer’s health plan pays for. This makes no economic sense at all – pay $35 cash or as much as $145 or 400% more  with insurance – for an office visit?

This is an excerpt that appeared in today’s issue of the Brownsville Herald:

A lawsuit has been filed against Cardenas Motors Inc., a Rio Grande Valley auto dealer, seeking to collect damages because of “misleading or deceptive acts or practices,” court documents say.

The lawsuit was filed Wednesday by The Zavaletta Law Firm, which is representing eight individuals who bought nine used automobiles from the Cardenas location in Brownsville and claim they where charged an unknown fee for services they didn’t receive.

The case was filed in Brownsville’s Cameron County Court-at-Law No. 3, with Judge Menton Murray Jr. presiding.

The fee in question is listed in the motor vehicles buyer’s order as “VIN REG” and it ranges from $392.18 to $798.18, said attorney Peter Zavaletta.

Editor’s Note: This is exactly what is happening in the group health insurance business, in our opinion. Hidden fees, or fees disclosed that offer nothing in return. Consumers should be incensed.

A Texas based TPA has fine tuned the art of maximizing lucrative revenue streams on unwitting employers. They employ a strategy of disclosing low administrative fees to gain the business, while hidding other fixed costs on the claim side of the ledger. Their contract includes a claim transaction fee on top of a pepm administrative fee, which is highly uncommon in the industry. Claims are unbundled as much as four fold and the claim transaction fee is applied to each. An “aggregate expense factor” is billed by inflating the aggregate factor in their proposal, then upon the sale they lower the agg. factor by as much as $12.50 and call that an “aggregate expense factor.”  When you add up all the fees, this TPA earns as much as $50 pepm and as much as $90 for each family unit per month. This, compared with the usual $15-$25 typical TPA fee, is outrageous.

The PBM contract is between the TPA only, with spread-pricing  which drives the group’s Rx costs up by as much as 62% (we documented this on one case).  Duplicate claim processing is charged at $25 per claim, in addition to the other fixed costs within their contract. And finally, upon renewal, the TPA presents a new administrative contract with a TPA name almost exactly the same but it is actually a different Texas corporation. The new contract states that they are not liable for anything the prior TPA may have done wrong.

This TPA preys on political subdivisions. They have brought the art of politics to a new level within the insurance industry.

A well known PPO network, concerned about their relationship with network hospitals, has decided to boycott any group that implements a cost-plus hospital reimbursement methodology. Notice has been given that any existing group that has implemented the cost-plus scheme must make one of two decisions: 1). drop the cost-plus scheme entirely or 2). PPO network will cancel their contract with the employer.

One wonders who the PPO network really represents? Do they represent the employer, or the hospitals that apparently can “make or break” them?

We think this PPO is short sight at best. Competing PPO networks are joining the fray, agreeing to work side-by-side with employers who use the cost-plus approach.

If you are an employer looking for ways to control your ever increasing health care costs. you might want to create your own PPO network and fee schedule. Building a network is easy to do (we have built numerous regional networks for several years) – and creating a fee schedule is easy too. While we are not recommending or suggesting you employ this firm – http://www.pfss.com/ – it will give you some idea of how easy and inexpensive it is to do.

Are you paying a monthly rental fee for your PPO network? Many self-funded plans do, paying on average $4 per employee per month. However, the PPO receives additional fees that are not disclosed to you, the employer. And these fees are paid by you in the form of higher claim amounts. We think that you would save money paying cash to providers rather than rely on a secretive PPO contract which you are prohibited from seeing. http://www.plexisweb.com/resources/white_papers/ppo-repricing.pdf

Here is a dental PPO fee schedule found on the internet for all to see – http://www.macombcountymi.gov/discountdental/pdfs/CI-5.pdf

If only we could access the same information on medical insurance PPO fee schedules. The problem is that PPO’s won’t provide you with the information citing confidentiality agreements. Yet they continue to tout thier discounts as the best, better than any other competing PPO. “Trust me, my discounts are at least 20% better than anyone elses out there.”

This is a well written article predicting the demise of PPO programs – http://www.libertyhealthgroup.com/images/61495/PPOs.pdf

GM&A of San Angelo, Texas, for the past ten years has been saving their clients millions of dollars in health care costs. They have done this by assisting employers in partnering with medical care providers on a fee basis that is fair and reasonable, rather than relying on PPO networks and insurance companies to negotiate “secret and confidential discounts” on their behalf.

For more information on GM&A, go to www.gma-usa.com. The Tyler Independent School District success story is worth reading.

                                                    

Does not take long for word to spread within the insurance industry it seems. A major national insurance brokerage is questioning the concept  of cost-plus provider reimbursement and is warning their clients and prospective clients against employing the strategy.  One would wonder why?

Could it be that undisclosed revenue streams to the brokerage, known to be paid by some insurance companies, and never disclosed to the client, could be jeopardized?  Could confidential bonus arrangements with brokers that are applied to each broker’s total book of business be affected?

For the reader’s information, a bonus arrangement on a broker’s total book of business is one way to hide compensation. So, when you ask the carrier if Agent Brown is receiving any kind of bonus on your group, they can honestly answer “no” since the bonus is pooled amongst all the broker’s groups and is not directly tied to your account.

There are other methods to “milk” the client too. For example, we have an email from a major insurance company to a broker outlining undisclosed compensation payable through the carrier’s pharmacy benefit manager. Here was the math outlined in the email:  254 employees X $9.34 Rx Rebate Amount)  X 12 months = $28,468 in undisclosed compensation above and beyond the $15,240 disclosed compensation ($5 pepm fee) and the 15% of stop loss commission.  Look for more information on this in a future posting.

Under a cost-plus arrangement, all monies are totally accounted for and fully transparent. That is a good thing.

 

If your agent recommends ABC Insurance Company, ask for a complete copy of his brokerage/agent agreement with ABC.

bcbsi-fedtradecom – but secrets are never secret forever. We have reviewed a BCBS hospital contract in it’s entirety.

When insurance consultants review and evaluate PPO networks, which networks are they really evaluating? In this case, are they properly evaluating United HealthCare’s PPO network or are they evaluating a network leasing agreement instead, or a combination of both?

nationet-physician-agreement  

This makes for fascinating reading – laredo-provider-community-conspiracy. Behind the scenes PPO physician contracting may be good material for a “whodunit” best selling novel.

Could a hospital administrator, whose hospital competes with another hospital five minutes away, have any financial intersts in the amounts paid to doctors who have admitting privilages at both hospitals?  With leverage applied to PPO networks, could a hospital administrator get better reimbursement rates for key community physicians who agree to “play ball” with steerage of patients to his facility?

There are a lot of unanswered questions it seems.

discount-de-bunking-healthsmart – Pay particular attention to the fourth slide – ever wonder why PPO’s wont give you their entire contract to review?

This is an interesting website. You can actually see PPO specific contracts posted here: http://www.empowerchiro.com/ClientLists.html

A Testimonial posted says: “Through my membership in your network, in the past 12 months, I have received $38,566.32.  Being a member of this network (FHA/EmpowerChiro) is a valuable part of my practice!”

Join the EmpowerChiro PPO network and start receiving patients with good insurance now!  EmpowerChiro has been bringing patients to chiropractors for nearly fifteen years. 

Here is a sample PPO network fee schedule you will find on this website:

TEXAS TRUE CHOICE FEE SCHEDULE
CPT DESCRIPTION ALLOWED FEE
98940 CMT (1-2 body regions) $ 25.30
98941 CMT (3-4 body regions) $ 32.20
98942 CMT (5-6 body regions) $ 37.95
98943 CMT (extraspinal, 1 or more regions) $ 25.30
99201 New Patient Initial/focused $ 22.77
99202 New Patient Initial/expanded $ 40.25
99203 New Patient Initial/detailed $ 45.77
99204 New Patient Initial/comprehensive $ 51.75
99205 New Patient Initial/complex $ 57.50
99211 Brief $ 17.82
99212 Focused $ 27.60
99213 Expanded $ 35.19
99214 Detailed (includes re-exam and manip.) $ 42.43
99215 Comprehensive $ 52.09
97260 Manipulation $ 27.60
97010 Hot or cold pack $ 13.80
97012 Traction $ 13.80
97014 Electrical Muscle Stimulation $ 13.80
97016 Vasopneumatic Devices $ 13.80
97024 Diathermy $ 13.80
97026 Infrared $ 13.80
97035 Ultrasound $ 13.80
97124 Massage $ 13.80
97530 Kinetic exercise $ 13.80
72010 Full spine AP/LAT $ 50.02
72020 Spine (single view) $ 28.98
72040 Cervical spine AP/LAT $ 47.72
72050 Cervical complete (4 views) $ 83.49
72052 Davis series (7 views) $113.85
72070 Thoracic spine AP/LAT $ 56.92
72100 Lumbosacral AP/LAT $ 55.43
72110 Lumbosacral with oblique $ 96.02

Note: Any code that is not included in the above CPT codes will be discounted 20 percent off the billed charge.

When payment is made, TTC will send repricing report to FHA then FHA will bill the provider 8% of the allowed amount to cover administrative costs. The allowed amount includes the insurance reimbursement plus the patient’s liability (copay, coinsurance and/or deductible).

 

Editor’s Note: See the last paragraph in bold – a provider re-pricing fee of 8%. This means that your claims are inflated 8% due to this “fixed cost” repricing fee, but it shows up as a claim cost on the claim side of your ledger. Most employers dont know about this fee.

Just for fun, go to the website listed above, click on Private Health Care System (PHCS) PPO network contract and compate to the Texas True Choice contract.

 

In the June 2009 Connections Newsletter, Humana writes:

“When it comes to helping self-funded accounts reduce their total medical expenses, Humana offers significant savings through out network discounts. Across the United States, we’re able to negotiate substantial discounts from hospitals, doctors, and other providers. As a result, ASO’s may realize greater savings by using Humana’s nationwide network that includes more than 350,000 providers.

In our major regions, Humana’s network offers discounts that average up to 20 percentage points greater than rental networks can offer – and is competitive with or better than other national carrier’s networks. In fact, if your clients are currently using leading national rental networks in these areas, they’ll likely improve their discounts by switching to Humana.

Editor’s Note: Humana is going out on a limb making these statements. How do they know that their discounts can be 20 percent or better than the rental networks? Have they compared contracts? All 350,000 of them? Now let’s see, Blue Cross touts that their PPO discounts are at least 20% better than anyone’s out there, now Humana says they are beating the rental PPO networks by as much as 20%, so if all of this is true, than Blue Cross has at least a 40% better discount than the rental networks (BCBS beats Humana by 20% and Humana beats the rental networks by 20%, so 20% + 20% = 40% better discounts). Of course, a discount off what number” Are billed charges with Humana higher than with rental networks? Or vice versa? Do providers have multiple billed charge masters? Will hospitals admit to that? What about doctors, do all doctors have the same contract? Is Dr. Jones contract with Humana better than Dr. Smith’s contract with Humana?

PPO Discount Games continue to be played towards ignorant consumers of care.

http://www.ncpolicywatch.com/docs/pdfs/BCBS_Contract.pdf See post below this post.

It is hard to cope with the dynamo known as Blues. Who is going to tell them what to do when they have about a 30% market share in Illinois with no competitor even close to that number? The “caring card” carries considerable weight with employees who equate it with security and the heavy advertising for the health plan that says they care. Employers have been known to be too scared to change away from the Blues, due to the perception on the part of employees, that there is no better coverage. The advertising that they do by sponsoring what seems to be every home run or first down in Chicago sports is effective. This will tell at least in part, how they can afford to pay for it, when most other insurance carriers can’t.

By the way, this article is not being written because we won’t do business with the Blues or because we see them as the only carrier with faults. However, over the years we’ve gotten tired of hearing the misconceptions and deceptions about what is being offered and how and why they are able to make some of the offers that they do. Suffice it to say that knowing how certain carriers operate can protect an employer from making a choice that can later make it difficult to move on to another vendor. For instance, knowing that the Blues continually only provide claim data that is outdated, helps one prepare for the fact that leaving the carrier will be difficult at best. If you would like us to provide an analysis of your current situation and an underwriting evaluation of where you stand, please feel free to contact us at mail@ssbenefits.net .

The Question is- Is what you see, what you get?

When receiving a group medical insurance proposal from the Blues, they can claim to have better discounts than the rest of the competing offers (be it a self-funded or fully insured plan) and their pricing to get the business will surely reflect substantial discounts. But now what? Will you as the client ever actually receive the full value of their hospital contracts or physician discounts? Most likely not. Will your broker or consultant advise you of the same? Most likely not. Many broker/consultants don’t have a clue how to experience underwrite and have even less of a clue as to how these plans really operate.

The Principles of Deception

Let’s look at a few things. Back in the mid-1980’s competition was stiff. There were a lot more insurance carriers. The TPA business was getting off the ground. HMOs were popping up in people’s garages, and PPOs were being added to indemnity plans. Managed Care was booming. What were the Blues doing? Offering proposals that included “negative retention!” (For those of you who don’t know, retention is the fancy word for expenses to run an insurance program.) Brokers were actually telling clients (and competitors quoting against the Blues) that the Blues could operate programs with less than zero expenses! You’d think there was enough common sense in the business to think something fishy was going on, but that is not always the case. There’s nothing like a juicy override agreement to override common sense.

So, how do they do that?

The answer is, they don’t. The Blues were ingenious enough to know the market was changing and they had the advantage. The advantage was their relationship with the hospitals and doctors. They had the original PPO, except nobody knew it other than them.

Let’s concentrate on the hospitals. The Blues provide an annuity to every hospital in their network. They have most hospitals in their network. Some would say every hospital in the Western Hemisphere . The hospitals depend on this “annuity” since the Blues are the dominant player in Illinois . (That’s not to say this isn’t or wasn’t happening in other states). The Blues reimburse all hospital claims to the hospitals at Cost, Plus roughly 5% profit.

Let’s say the hospital charges are $10,000, but the cost is really $7,000. Cost plus 5% is $7,350. The Blues pay $7,350 to the hospital and keep the $2,650 profit. By keeping the difference, but charging the client as though the claim was for $10,000, the Blues could claim that there was no retention due to the profit they were taking (but charging as a claim to the client). The claim report to the client shows the $10,000 in hospital charges. (By the way, do you think the employee paid coinsurance on $7,350 or $10,000?)

Well, you say, what about PPOs?

Surely things are different there. Well, yes and no. The hospital accounting still is applicable, but new items have been added. The Blues have had to give up some of their profits in order to compete with other PPO plans, but they have still found a way to keep more than most. Negative retention had to give way and eventually disappeared, once they had to give up some money and show some PPO discounts.

Access Fees you will not believe

One of their brilliant ideas that most don’t catch is that they charge for access to their PPOs as a claim charge rather than identifying a per employee fixed monthly fee (we can’t recall if they had this idea first or stole it from First Health/Affordable).

Their charge for accessing the PPO can amount to as high as 28% of projected net paid claims (including non-PPO claims). On one case reviewed, that charge amounted to $31.11 per employee per month (and this was before the pooling and risk charges were added and the whole amount was divided by the objective loss ratio to make the charge even higher). That is far higher than the usual $3 to $6 per head that most independent PPOs charge.

But that’s OK, the discounts are greater with the Blues, aren’t they?

Maybe the Blues discounts are greater, but we will never know. Unlike (most, but not all) other carriers and third party administration arrangements, the Blues never show their actual discounts.

When we underwrite and review network performance, we usually like to separate billed charges on an In and Out of Network basis. Then we remove ineligible charges from the amounts billed In Network and see what the discounts were compared to actual eligible In Network charges. This gives a more true picture of the discounts achieved.

The Blues only provide their discounts on renewal as projected savings. You never get to see what the real number was! The number initially looks pretty good at 35% to 42% of projected paid claims. But, if you look at other networks with good coverage, as a percentage of actual paid claims, the discounts are usually much higher (50% to 55% of actual paid claims), with access charges that are far less. Remember, most other networks report their actual discounts too, so you actually know what you are getting for your access charge. So, the Blues might have better discounts, but chances are that you, the employer, may never benefit any more than you would with another network. In fact, you may end up paying more.

There are other tricks that are used by companies to overcharge for network access or overstate their discounts. You can review on this web site another article on that subject in THE TRUTH section of the web site.

What about that National Network?

Yes, there is a thing called the Blue Card network that can make sure that you have the opportunity to be in network on a national basis or cover your employees in other states. Just be aware of a few things. Those other state plans get the claim first and then process the claims with the local Blues. It is not a seamless proprietary network. Each Blues plan wants their piece of that discount pie. The delays can also be a bone of contention, since the delay can cause duplicate bills. If the Blues charge for access to the network as a percentage of network savings (as they have been known to do), how do you know you aren’t being charged for savings on duplicate charges due to delayed payment?

 

Underwriting

Needless to say, with the discount game being played, there is lots of room in underwriting to price for the competition. They may have to give up something in the rates on the front end, but the profits will most likely be there. The Blues also like to give claim experience that is six months old as part of their renewal. This makes it especially difficult for other carriers to underwrite, since the usual standard is to have claims experience that comes to within at least three months (and preferably two) of the proposed effective date. This helps the Blues to insure that you will receive higher than normal quotes from the competition. Underwriters from other carriers view Blues experience with trepidation, since the discounts are unknown and the experience is old. This forces the competing underwriter to be conservative in their assumptions.

The Blues (unfortunately now other carriers are following this poor example) also won’t provide experience on groups of less than 150 employees, although they want that experience if the group is over 100 lives and you want them to quote. Makes sense? You’ll also have to cite federal law and fight with them a bit to get Schedule A information for a group of less than 150, even though the IRS demands the information for a group of over 100 employees.

What the Blues have been able to do is successfully continue to market their market dominance by appealing to those who fear they may not have the same coverage elsewhere. For employers, the fear of employee reprisal and discontent is often enough to get them to accept some pricing tactics that they would not accept from other insurance carriers or third party administrators. Those brokers who continuously push the Blues are easily motivated to do so by override agreements to commission arrangements that Eliot Spitzer has no need to challenge, since they are not in his state. The weak and continually changing insurance commissioners in Illinois are not about to challenge the Blues and their tactics either.

Editor’s Note: Author of this piece is Jeff Seiler, an Illinois insurance consultant. His web site is www.ssbenefits.net. It pays to read contracts, if you can get them for review. This is especially true if you are a third party beneficiary but not a party to the contract. A journalist in North Carolina has done a little work in that area – http://pulse.ncpolicywatch.org/2009/03/18/blue-cross-takes-state-to-the-cleaners-in-contract/

If your a physician in Illinois, and dont remember what you signed with BCBS, request your fee schedule here – http://www.bcbsil.com/PDF/fee_schedule_request_form_BlueChoice.pdf

 

http://www.businessinsurance.com/article/20090626/NEWS/906269991

http://www.reason.tv/video/show/560.html

See indictment here – https___ecftxsduscourtsgov_cgi-bin_show_temppl_file677145-8843129-0-headed_lm

Letter received today from the Cuero Livestock Commission to Martha:

Congradulations. Your calf was the highest priced calf in its weight class. The attached slip came from the market report that the computer program generates from the sale each week. It comes from all classes of calves in each 50 pound weight class. We like producers to know when their calf tops the entire sale for its weight class. So we thank you for your business and again congratulations on topping the market.

More bad news for ethics amongst insurance agents in the Lower Rio Grande Valley, Texas. Mr. Arnulfo “Half Guilty” Olivarez, admitted felon and still licensed insurance agent, awaits his sentencing on August 14. Aaron Gonzalez, former and defrocked insurance agent from Elsa, is also awaiting his date with destiny after having his sentencing postponed more than once. Now another insurance agent from the Valley is accused of evil and illegal activities.

Ethical insurance agents suffer from the broad brush of public opinion whose only source of information are news announcements of insurance agents gone bad. That’s unfortunate.

 

http://www.valleymorningstar.com/news/carter-54429-fraud-insurance.html

Individuals can enroll on a dental insurance program in minutes by going to www.dentalcoverageonline.com

This plan is one of the most competitive individual dental plans we have found. Rates are comparable to group rates. We compared this individual plan to a voluntary group dental plan in a 7000 life South Texas school district and found the individual dental rates to be slightly lower than the group rates, with comparable benefits.

Sometimes it takes a lawsuit to find out how much you are paying your insurance broker. This is a exerpt taken from a lawsuit in South Texas that reveals the broker who placed the business with this political subdivision was paid 50% of the TPA’s administrative fees.

If your interested in controling your health care costs, a visit to AWAC is mandatory. Below is an excerpt from their website:

AWAC® or Advanced Warning and Containment®, a product of AWAC, LLC, is a sophisticated new way to save health plans money, while also improving patient outcomes. AWAC’s proprietary software actually detects situations that are likely to become catastrophic before they reach that state and makes recommendations. The AWAC multidisciplinary team of physicians and clinicians devise and implement a strategy or intervention, ultimately resulting in lower claims costs and healthier patients.

Dr. Richard’s Rules for IT:   1. He who has data wins. 2. He who has good data wins a lot. 3. He who has good data in real time wins it all.

http://www.insurancetimes.co.uk/story.asp?sectioncode=13&storycode=378872&c=2

With the passage of a national health care plan will come health care rationing and long waits to see a doctor. Certain surgical procedures will require governmental approval and months if not a year or more wait time to have the needed surgery. Such is the nature of socialized medicine as evidenced in Canada, United Kingdom and other countries that have embraced the socialized medicine concept.

Physicians in the United States will be mandated to accept 110% of RBRVS through the govenment plan and will be required to see patients who participate in the socialist program. Since it is estimated that 62% of all United States physicians are over the age of 55, we suspect that many will retire early leaving an even greater shortage of physicians in this country.  With an estimated 50 million additional health care participants covered, it does not take a rocket scientist to see that health care in this country will be necessarily rationed and waiting lines will be long.

These are undeniable facts.

What we expect to see is the rapid rise of competitive health care schemes for those able to seek and pay for care in other countries such as Mexico, Costa Rica and Singapore. High quality care is available overseas with costs as low as ten cents on the dollar as compared to fees charged in the United States.

It is estimated that over 1 million Americans will seek health care in other countries in 2009, up from approximately 500,000 in 2008.

We are currently working with several overseas organizations to help facillitate access to quality health care in Mexico, Costa Rica, India and Singapore. We are finding that some of our clients are willing to look at this option now, and we expect this interest will grow once Americans realize what “free” socialized medicine really means to them personally.

http://www.cmi-matamoros.com/

www.globalmedicalprices.com

Highmark, a Blue Cross Blue Shield plan, has opened two health insurance retail stores in Pennsylvania, called Highmark Direct.  With a national health care delivery overhaul expected this year, Highmark may be on the leading edge in positioning themselves under the new system Congress is expected to pass before Labor Day. Read full article here – store-front-health-insurance

A Dallas Friend of Mine Shared This With Me:

John C. Goodman Health Alert
I have glimpsed at the future of U.S. health care and I am pleasantly surprised. Instead of
continuing to rise at twice the rate of growth of income, health care spending will slow
dramatically. Future prices will actually be lower than they are today. Providers will
bundle their services into easily-understood packages with a single fee. They will compete
against each other on price and quality and the data will be transparent. Health care will
be provided in a free, competitive marketplace. Third-party insurance will be relied upon
only for rare, very expensive events. Medical malpractice suits will be virtually unknown.

There is only one catch. All this will happen outside the United States.

Cheers,

John Goodman
President and CEO
Kellye Wright Fellow
National Center for Policy Analysis
12770 Coit Rd., Suite 800
Dallas, Texas 75251
http://www.ncpa.org

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?printable=true

Good Afternoon,

below please find our new format for the monthly industry related articles I have been sharing with you.  Hopefully you are finding them informative, as well as useful.  If you missed any of the previous ones, you can print out a PDF copy below.

This month we are discussing “Fair and Reasonable Reimbursement”.  Would love to have any feedback you might have, as well as discuss how NCN could assist you.

Patti Brock-Chapman
Director of Business Development
NCN
222 West Las Colinas Blvd
Ste 1500, Urban Towers
Irving, TX 75039
972-373-2800, ext 114
pbrockchapman@ncnelink.com

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NCN Takes a Hard Look at Healthcare
The Fifth in a Twelve-Part Series
May 2009

Claim a Better Way

Now, for the first time in the industry, NCN powered by Data iSight can give payers, providers and patients access to the exact same information. This new, patent-pending reimbursement methodology ensures a variety of other benefits to all three parties as well:

Transparent Reporting to all parties facilitates open dialog and builds trust.
Defensible Methods are based on solid data to validate settlements and streamline the negotiation process,
Repeatable Results provide consistency over time and prove the superiority of the solution.
Lower Cost means increased savings for payers and patients on claims of any size.
Efficient Turnaround means providers aren’t kept waiting by the process.
Get Data iSight, the solution that benefits all parties with lower costs, greater savings and more peace of mind.

Questions or Comments

pbrockchapman@ncnelink.com<mailto:kbattaglia@ncnelink.com>

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What Constitutes a Fair and Reasonable Reimbursement?

[X]
Capturing savings in healthcare claims is important. Our rich media presentation, What Constitutes a Fair and Reasonable Reimbursement?<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5TY-cTR2bL_d8kiTd4PXm8MwaaGeEIyIh0C4VYCGG9s3MRsfT6AElN4Gq4bW9KfMytnQn1iNCM33G7RxNEvGQwAnI1R4vb87hHsQlu-I4fZYNey8XpmF7CDwMshLhoN-sA_5XYz_Rvz9Cw==>, explores:

*

All Over the Map – Healthcare suffers from erratic pricing methods.
*      An Unsustainable Model – Saturated healthcare markets can’t deliver promised savings.
*      An Unbiased Benchmark – Third-party data holds facilities accountable.
*      A Solution in True Cost – Cost-based methods change the trend of rising healthcare charges.

PDFs of Articles

Here are links to all the articles in our series, NCN Takes a Hard Look at Healthcare:

What Constitutes a Fair and Reasonable Reimbursement?<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5TYvAj6QR7jnPeEkdbJ-p6qA3eEpQgQhLMlomTAtN0LdiBBLFzQSeYX81n1LNr8uB-9eOWYTC_sX7xU89vGC7zWdInp4UpsjLoxzn4s4hu_5_IlNxjvPzufyuacQCwY_3AxScg4HBthjHQdRpKWErUXm_EPH5ccFx3crBhnZXCAX6LnoeSccuJGT>

Out-of-Network is a Good Place to Start When Trying New Technology in Healthcare<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5TYb6ZoL6K7wKEHs3DVwVBxR8i8dsMVJIGW4xtVdwgW_7nkBv4lw1vXTHwVrT35vxTgRgukuNx5GJMEGF13Itp3XzvBy1bu6KErCBMC6OqSx78bhGXdyCOZLpABk1k4mHFDArFO25C5moxYTVKHSsWEOUZABF3LCX4EKdFTdCgzVjY1RcmxxGLcZAbTswIYO3_4=>
<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5Tb-qDWoOV-RBANMx-Bn-uvYNYK6tCY-cGjp5ObLt075CcBRlLHFRVrTX1wjB49L17icp6CKpDl2DHnwA6hh2r3OWoOnQO9eNB5ouOZmAPNI6w==>

Are PPO Networks Relevant?<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5TaBBl8y2VpKY95fJnQKi1JtuukvOKDYqja3cTBnvbodi8VWZHZSkKaQA5d2gSWdipSParNCRsh43ZF1x0jPTvHY0AhWfebgzSUz3A7iqBV9vQQ9e7ls1DiQzhAwMu9bPMcgGd3v8zKETq6nT4FG7nhkBuYdnrapIPQ94j1VyMLfg_Sn5FMRyBoH> <http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5Tb-qDWoOV-RBANMx-Bn-uvYNYK6tCY-cGjp5ObLt075CcBRlLHFRVrTX1wjB49L17icp6CKpDl2DHnwA6hh2r3OWoOnQO9eNB5ouOZmAPNI6w==>

Costs vs. Billed Charges: What’s the Difference?<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5TaPG8hENCJCpHtOkTpLEqAkwtUvKKV2aSeDN7aiVBqKJN_b6qIgeyB-6gqKQp_mZ_l9Mzo3IoQ-kztMbprCny8NrD3iu6pPWVbPTYY4VmeAkLEnS7M0bsqYX9JxPC1Y2wcwn3ZLHJArVfuR5gVYdaI_8Wray-N4ocqbDmx4WGZkRRdgurz1Fc7BxOf7PLQiEmw=> <http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5Tb-qDWoOV-RBANMx-Bn-uvYNYK6tCY-cGjp5ObLt075CcBRlLHFRVrTX1wjB49L17icp6CKpDl2DHnwA6hh2r3OWoOnQO9eNB5ouOZmAPNI6w==>

Can Transparency Really Reform America’s Healthcare?<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5TYvBVyfi5cDFqjhtOvWz9okwkh_CPEqZz5MOZo-v3Qji3olkCV_bc2C9DFbqwUrfdp7NFQN4wPBCmlpfRgFVwovXSuaq-SzQPyCSrkiPBsOLqPytHhaDWWlF-cSk-a6wj2VUJmuFi-mW-IFKpokee3v6OEJBOxlRE5AU7CLhT76Pc4DhFFqDjo->

About NCN

NCN<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5Tb-qDWoOV-RBANMx-Bn-uvYNYK6tCY-cGjp5ObLt075CcBRlLHFRVrTX1wjB49L17icp6CKpDl2DHnwA6hh2r3OWoOnQO9eNB5ouOZmAPNI6w==>
[X]
is the national leader in cost management for out-of-network claims. We use cost-based data and transparent reporting to maximize savings on healthcare claims. At NCN, we claim a better way for payers, providers and patients. View a rich media presentation about NCN’s patent-pending cost-based methodology.<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5Ta9XgSHtshdIMCQLcjzihLKSVy6ZeZiwWr5CvrRC0wnN1nxuGNgC7eig4I4_P35XeLY8nRJ9q2aDIBVu1upnOCMRG9rS_oUeXNHLboVA4Zh5BsnHUYf7lC9GlIBno2JiPFKSEaX_P0U0Q==>

NCN at AHIP’s Institute 2009

If<http://rs6.net/tn.jsp?et=1102587100702&s=29&e=00172ABKRdj5Tb-qDWoOV-RBANMx-Bn-uvYNYK6tCY-cGjp5ObLt075CcBRlLHFRVrTX1wjB49L17icp6CKpDl2DHnwA6hh2r3OWoOnQO9eNB5ouOZmAPNI6w==> you’d like to meet with NCN reps at the Institute in San Diego, please contact Kelly Battaglia<mailto:kbattaglia@ncnelink.com>, Manager of Marketing Services.

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The Health Care Battle Begins

Sen. Edward Kennedy (D-Mass.) has begun circulating drafts of his proposed health care reform legislation. Initial reports, including an op-ed in the Boston Globe by Kennedy himself, suggest that the bill will contain every one of the bad ideas that I outlined in my recent Policy Analysis on what to expect from Obamacare.

Among other things, the Kennedy bill will call for:

-An employer mandate;
=An individual mandate;
-A so-called “Public Option,” a Medicare-like plan that will compete with private insurance;
-The use of comparative-effectiveness/cost-effectiveness research to restrain costs;
-Subsidies for families earning as much as 500% of the poverty level ($110,250 for a family of four).
-Insurance regulation, including guaranteed issue and community rating. (He would also establish Massachusetts-style Connector); and Government-directed health IT.

There’s no indication yet of how much the plan would cost or how Sen. Kennedy plans to pay for it.

The bill will be formally presented to Senator Kennedy’s Committee on Health, Education, Labor & Pensions (HELP) sometime next week. Hearings could be held around June 10, and committee “mark up” could begin on June 17.

Senate Finance Committee chairman Max Baucus (D-Mont.) is expected to introduce his health care bill shortly before the Finance committee begins its scheduled mark up on June 10.

Meanwhile President Obama’s campaign apparatus is planning rallies and demonstrations around the country to build support for health care reform.

The battle over the future of health care in this country has begun.

Dr. Pruitt, a Ft. Worth dentist, understands the problem with “dental insurance” and is not afraid to speak out.

http://healthcarefinancials.wordpress.com/2009/04/06/direct-reimbursement-dr-and-riskmanagersus/

Brownsville Independent School District is seeking proposals for insurance consultant. This is the second time in the past two months that the BISD has sought proposals for insurance consultant. Apparently the Board of Trustees did not like the choices presented to them on the first go-around.

The administration’s recommendation was to re-hire the current consultant. One board member commented “why are we going to re-hire a consultant who last year recommended a change in PPO networks to save us money, when in fact we have not saved any money and are spending more?” A motion to approve died for lack of a second.

Proposal specifications will be released via the BISD website soon.

Editor’s Note: Can anyone verify that the current BISD PPO network has less provider discounts than the previous BISD PPO network of last year? Has anyone reviewed actual PPO provider agreements with the two Brownsville hospitals to compare? Has anyone reviewed each and every physician PPO agreement for all physicians in Brownsville and surrounding communities? Are all physician PPO contract the same, or do some physicians get paid more than others? Are 100% of the PPO “discounts” passed on to the consumer? Do PPO contracts contain excalater clauses that assure providers a “pay raise” every year? Do all PPO contracts with providers renew at the same time every year, or are the contracts renewed as the preceding contract term expires?  Has anyone asked the two Brownsville hospitals which PPO network would provide BISD with the lowest health care costs?