Uncategorized – Page 5 – Risk Managers

Annuity Contract Interest Rates

Managed Care Networks Don’t Justify The Volume

By Ryan Kline

In the next year we’ll see a provider terminate a carrier network contract without losing a single patient. They’ll realize that the cost of doing business with the carrier no longer justifies the volume.

What A Difference Network Pricing Makes!

By Brian Cotter

901% of Medicare. Or 1,653%. Same rate. Different denominator. I ran the math at NYP. I pulled every payer rate for MS-DRG 871 (Septicemia) from NYP’s price transparency file and benchmarked each against four versions of Medicare.

Compliance Gaps in 15 Minutes: A Door-Opener for Advisors

By Dave Chase

Here’s a number that should reframe how you think about first meetings. 87% of employers have identifiable compliance gaps. Not potential gaps. Not theoretical exposures. Gaps you can find in 15 minutes with the right diagnostic.

Saving Healthcare: Putting all the Pieces Together

We’ve talked about practice/hospital management, health and wellness, EMR and integrated coverage, now let’s look at the big picture

Selecting The Right PBM

By Daron Pitts – President and Stop Loss Placement Specialist at XL Benefits Insurance Services, Inc. – Visit my website

Just rolling with whatever PBM the TPA prefers or recommends versus really doing due diligence could be the difference of thirty percent in Rx costs.

Cotter Wisdom

Same DRG. Same market. Five times the price. The variation is real. Build your network around that reality.

Health Insurance Made Easy

ACA Compliant Health Insurance

PBMs Made Simple

By Shea Dimauro

PBM 101 is an educational series designed for self‑insured employers who want to better understand how pharmacy benefits actually work.

Changing Behavior Doesn’t Lower Health Care Costs Because We Love Grandma

Grandma smiles devilishly while preparing toxic dish

“Lets put in a Wellness Plan!” says Linda in HR. “Our employees will become healthier! Healthier employees need less medical care and less medical care means lower health care costs!”

% of Something Is Not A Price In American Health Care Finance

By Brian Cotter, MPA HSF

120% of Medicare. 50% Discount off Charges. Misused & Misunderstood. Neither is a price. Avoid putting either term in a contract without further definition. They are formulas…that can be manipulated!

There Are Alternatives To High Cost Traditional Health Insurance

Family premium $2,000 a month + $7,500 deductible = $31,500 total out-of-pocket during a 12 month period before “real” insurance benefits begin.

Two Hospitals Blocks Apart, Same % of Medicare = Very Different Payment

The figures above use Hospital-with-Supplementals, the layer most people mean by “% of Medicare.” Bellevue is a public safety-net hospital. Its DSH and uncompensated care.

Risk Management – Winging It Isn’t A Business Strategy”

“You can’t fix what you don’t see. You don’t know what you don’t know. We see opportunities others miss. We do what others don’t. Winning together is our goal.” – RiskManager.us

Snake Killer Consultants vs Animal Rights Consultants

“I come from an environment where if you see a snake, you kill it. At GM, if you see a snake, the first thing you do is hire a snake consultant. Then you get a committee on snakes and discuss it for a couple of years.” – Ross Perot

Will Roger “The Teflon Kid” Survive Another Assassination Attempt By The Brownsville Independent School District?

Roger Garza, the cat with nine lives……………..

Will Roger Garza “The Teflon Kid” survive yet another attempt by the Brownsville Independent School District board of trustees to terminate his insurance consulting agreement? How many bites of the apple will it take?

Want $1,000 In Free Retirement Savings? Visit The New TrumpIRA Site

President Donald Trump is set to sign an executive order creating the TrumpIRA.gov website, which will let workers without employer retirement plans enroll in private-sector plans and tap into the Saver’s Match program that offers up to $1,000 in government matching contributions. The move aims to address the fact that a large share of full‑time and part‑time employees lack access to retirement savings options.

Knowing When Your Client Is Really Not A Client Anymore

By Bill Rusteberg

When a client won’t decide, won’t act, and won’t take guidance they’re not really a client anymore—they’re stealing your time and you’re stealing their money.

ATTENTION HR – Turbocharge Workers With Brain-Boosting, Productivity-Jacking Stimulants

Update your Rx formulary and unleash the power of dopamine. Increase productivity. Turbocharge workers with miracle drug……………

% Of Medicare Uses A Denominator Nobody Defined

By Brian Cotter

Actuarial report every plan sponsor should read: Milliman says “% of Medicare” has no default definition. Your contract uses a denominator nobody defined.

What’s A MRF?

Bill Rusteberg – 3rd Grade (first row, left) : What’s a MRF?

Phil Harrison : Hi William – MRF’s = Machine-readable files (MRFs) – we throw acronyms around in healthcare like there’s no tomorrow.

Houston Methodist Is Sexually Inquisitive

“This is one of the intake questions posed by Houston Methodist when you register at their hospital” – Mary Talley Bowden MD

Do PBMs Know The Exact Amount of Rebates Per Prescription?

Do PBMs negotiate rebates with manufacturers? Do aggregators share rebate accounting with their PBM customers? Some say yes, some say no. Who’s right?

How Do Insurance Companies Make Money On Life Insurance?

How does an insurance company make money on a 30 year old paying $13 per month for a $100,000 term life insurance policy? At that price it would take 641 years for premium to equal the death benefit.

Texas Based Rebate Aggregator

SOURCE: Leaf Health

Leaf Health is your connection to the pharmaceutical manufacturer and your partner in rebate aggregation.

Understanding Rebate Aggregators

SOURCE: Understanding Rebate Aggregators

The US pharmaceutical supply chain is complex. It involves numerous participants and intricate contracts that ultimately determine the cost of prescription drugs for plan sponsors. In recent years, a new entity has emerged, known as Rebate Aggregators. Let’s dive into what you need to know about how rebate aggregators fit into the supply chain.

If PBMs Are Bad, Why Do We Still Use Them?

By Bill Rusteberg

It’s clear no one likes PBMs…….. except hedge funds. There’s not a day goes by that we see yet another wash, rinse and repeat “PBMs are The Bad Guys” article along with an AI generated graphic to prove it.

Leon “The Magician” Believes “Build It & They Will Come”

No doubt money is tight. Companies are reducing cost. Everywhere. One easy way to save is to not overpay for the price transparency data. Some companies charge an arm and a leg for this data. And the front-end tools stink.

Are Your ‘Voluntary Benefits’ Really Exempt From ERISA? It’s Worth Checking

HIGHLIGHTS

Employers have been found to improperly endorse voluntary benefits where the employer permitted employees to pay for the voluntary benefits on a pre-tax basis through the employer’s Section 125/cafeteria plan. TRANSLATION: IF VOLUNTARY BENEFITS ARE PRE-TAXED THE EMPLOYER IS SUBJECT TO ERISA’S FIDUCIARY OBLIBATIONS.
An employer may be found to have received consideration for voluntary benefits if the employer benefits from use of commissions related to the coverage to pay for such things as a “free” online enrollment system. TRANSLATION: FREE CAFETERIA ADMINISTRATION AND ENROLLMENT PLATFORMS ARE NOT FREE – SOMEONE IS PAYING AND IT’S COMMON FOR INSURANCE AGENTS TO CEDE A PORTION OF THEIR COMMISSIONS TO BE ABLE TO TOUT “FREE, NO COST” ENROLLMENT SYSTEM.
If the “voluntary benefits” exemption does not apply the employer’s obligations would include compliance with ERISA’s fiduciary obligations. TRANSLATION: EMPLOYER IS OBLIGATED TO PRACTICE DUE DILLIGENCE IN THE PROCUREMENT OF VOLUNTARY BENEFITS AND MUST SEEK FULL COMPENSATION DISCLOSURE FROM INSURANCE AGENTS SELLING PRODUCTS. n
Not all PLAN SPONSORED benefit plans are subject to ERISA

Client Lists Are Prospect Lists

Closely guarded client lists are hard to keep secret these days. Providers often publish lists of plans they accept as in the example shown above.

ClaimDOC Cash Pay Program

By Omar Arif

Another reason to work with ClaimDOC…. We run a cash pay program called MedCash that fronts money at point of sale to solve member access issues quickly. Finance just told me we’re in the hole to the tune of 900k at the moment. We’ll get most of it back, the only exception being clients who work with rag tag TPA’s.

Look Out Hospitals. The DOJ is Catching Up With You

“The only way to win as an employer is to dictate what you’re willing to pay. No one can afford to accept these prices anymore”. – Omar Arif

“Reference Based Pricing might be a solution here, but with systems making demands like this, you can bet they’re not playing ball in the RBP world. Without any oversight, these systems will continue to do as they please, raising rates, demanding status, taking out competition. Plan sponsors lose one of the few impactful strategies available, which is plan design steerage. Which, of course leads right back to the demise of healthcare as hospital systems gobble up what they can to create mammoth, monopolistic systems”. – Julie Wasserman

Gonzaba Medical Group: From Barrio Clinic to Medical Empire

Dr. William Gonzaba, affectionately known as Dr. Bill, still loves to see his patients

Bill Gonzaba is one of the most memorable characters I’ve met in my +50 years in the insurance industry. I was fortunate enough to have met Dr. Bill on several occasions at his office on the South Side of San Antonio. His style of leadership was collaborative, ceding his trust to those around him yet always maintaining unspoken yet deferred dominance – Bill Rusteberg

Better Healthcare. Less Cost. Real Freedom.

SOURCE: Health Freedom

We cut out the middlemen and put you in direct control of your healthcare. $0 access fees, real price transparency, and actual competition — the way American healthcare should be.

Hospital Billing Fraud?

By Bill Hennessey, M.D. – The Doctor of Healthcare Cost Savings – Visit my website

WVU Hospital Commits Fraud by Using Revenue Codes to Unbundle and Financially Extort Its Community

Citizen Exposes True Cost of AI Infrastructure on Water, Power and Jobs

Will Hollingsworth, a former programmer, delivered a masterclass in public testimony against the construction of a new AI data center.

The Classic 105 Wellness Program Scam

By Chris V. – ERISA Attorney | VP @ Sequoia

CFOs, if a vendor has pitched you a “wellness program” that saves six figures a year in FICA and payroll taxes at no cost to the company, you’ve been pitched a scam that’s been running for about 20 years.

Hospital Lays Off 600 Employees Due To High Cost GLP-1 Drugs

One nonprofit hospital system in Pennsylvania, Jefferson Health, said the cost of GLP-1 drugs has jumped to 40% of its insurance spending. As a result, the organization’s CEO, Dr. Joseph Cacchione, stated the issue led to more than 600 employees being laid off.

Ready For Complex Open Enrollment Questions? AI Agents Can Help

By Paola Peralta – April 20, 2026

The key to making the open enrollment process more efficient and effective for both employees and benefit leaders may be to hand questions over to AI agents.

Capitalism vs Socialism Is The Wrong Fight For American Health Insurance

The third path is older than either of them……People’s Capitalism……….. local control, personal responsibility, voluntary association, government staying out of your business.

Shopping For Insurance Is As Easy As Booking A Hotel

Oscar Health Launches Consumer Marketplace – “More proof this is the future and the future is now” – Bill Rusteberg

Health insurance – Dental insurance – Vision insurance – Short-term health insurance – Accident insurance – Critical illness insurance – Cancer insurance

“When shopping for healthcare becomes as easy as booking a hotel, we can eliminate decades of inefficiency,” Bertolini said.

Pink Claw Report

Article Referred By Pink Claw

The year is 1950. Your doctor lights a cigarette and tells you smoking is fine. He read it in a study. He is telling the truth about having read it. He does not know, or is not saying, that the study was funded by the tobacco industry.

Freddy Fender Dedicates This Song To All Those Poor Bastards That Don’t Get It

Attention Insurance Brokers: Need Request For Proposal practice? Here’s your chance……….

Attention RBP Plans: “% of Medicare” Is A Ratio, Not A Price

“If your plan design is built on “% of Medicare” and you are using it to steer members toward lower-cost hospitals, you may be steering them toward the wrong ones…………”

Aldeen’s Sunday Morning Bathroom Read – NSA Edition

Doug Aldeen – ERISA Healthcare Attorney and Fractional General Counsel – Visit my website

A federal judge has dismissed one of the four pending civil lawsuits against HaloMD, a company that represents providers in No Surprises Act arbitration cases.

ParetoHealth SaysTraditional Health Insurance Is Broken

ParetoHealth empowers small and midsize employers (50-1,000 employees) with a long-term solution to reduce volatility and lower health benefits costs.

Self-Funded Health Coverage for Businesses

SOURCE: Nationwide /

Our self-funded solutions are designed to provide affordable health benefits for small and midsize businesses

Cash Pay Health Care Isn’t Rocket Science

By Bill Rusteberg

PROPOSITION: Members never generate claims for 60–80% of care. Plan intercepts as many health care encounters as possible before becoming a claim and routes into a cash-pay pathway. Everyone wins. Patient wins, plan wins and providers win.

The Care Nav Health Plan

SOURCE: Fix Healthcare | The Care Nav Health Plan

“You can completely replace member services with awesome plan advocates and nurses called Care Coordinators. They provide navigation, advocacy and clinical support to your people. They steer them through the traditional parts of the plan and also the modern point solutions that greatly enhance the member experience while significantly lowering claims cost.”

Shop for Provider Quality and Cost of Care & Get Cash Back

SOURCE: Find a fair deal for medical services

Let our team of Patient Advocates, Nurses & Physicians guide you to High-Value Doctors & Facilities where you can earn cash back rewards and save hundreds even thousands on medical services.

“FREE” Program

Financially Rewarded Employee Engagement

The “FREE” program is an employer-sponsored initiative designed to incentivize employees to utilize healthcare services via a designated Patient Navigator. In this program, the employer covers the entire cost of these healthcare services, providing them to employees at no out-of-pocket expense. The initiative is financially advantageous for the employer as it substantially lowers overall insurance costs by promoting the use of cost-effective healthcare services.

Navigation Health

Employer Health Plan Solution Big & Small

The NAVZERO Health Plan is a robust major medical plan that meets and exceeds ACA compliance. It can be sold as level funded or self-insured, depending on the size and risk appetite of the employer group.

Most Workers Don’t Have Access to Flexible Benefit Cafeteria Plans

Tax Savings on Voluntary Benefit Plans Eludes Most Workers

Five Myths That Are Driving Health Care Costs For Employers

By Morgan Kendrick, Brand Contributor. for Elevance Health, SOURCE Forbes

Apr 16, 2026

Healthcare costs are rising in part because of assumptions that go unchallenged and are quietly undermining the cost of care.

Infuse Your Benefits with SOTA

SOURCE: Sota Benefits.

As a Health Insurance Program Manager, we design and deploy modern insurance solutions for employers and brokers. Our goal is simple: to infuse value into healthcare by providing high quality, high service solutions at the lowest possible cost. Experience the SOTA difference today.

Chances of Winning A RFP

By Brad O’Neill – The ICHRA Architect,ICHRA Pioneer aka The Wizard of ICHRA,Guru of Choice Benefits

Most brokers think the #RFP is an opportunity. It’s not. It’s the confirmation.

Best Benefits Is Your New Best Friend

Best Benefits Online™ modernizes employee benefits with real choice, and zero admin complexity—all in one platform.

A modern, sensible and common-sense solution for employer sponsored health plans and associations.

Meet the next generation of employee benefits

Zorro redefines employer-sponsored benefits with the industry’s most tech-forward, people-centric ICHRA solution.

Baylor Scott & White Health Plan to stop offering Medicaid and marketplace health care coverage

Medicaid and individual marketplace plans will no longer be carried by the insurer, impacting 225,000 Texans.

Why Would Any Employer Want To Be In The Health Insurance Business?

By Bill Rusteberg

Why would any employer want to be in the health insurance business? The answer is most don’t. But the reality is they end up there because many are forced into the role by the Affordable Care Act whereas back in the day they were in because they wanted to be.

America’s Largest City Hospital System Ready to Start Replacing Radiologists With AI, Its CEO Says

Mitchell Katz Having His Head Examined

“Only someone with zero understanding of radiology would say something so naive.”

What Liability Theories Underpin the Latest Group Health Plan Litigation?

Experts answer questions regarding plan sponsor fiduciary duties for health benefits.

A Different Kind of Captive – Cow Share Risk Pool

Soon To Be Table Ready Captive poses for article…………….

INVESTORS HUNGER FOR CAPTIVE INVESTMENT RETURNS

Health Care Sharing Ministries are associations of people whose health care costs are pooled and shared among members. It’s a simple, uncomplicated arrangement that cuts out value-draining middlemen.

Direct Primary Care Membership For $8.25 Per Month!

One Medical, a modern approach to healthcare. This is no ordinary doctor’s office. We make it faster, easier, and more enjoyable to get care.

Life Insurance For Veterans

If you are an active duty, reserve/guard, or retired servicemember in any branch of the United States military or uniformed services, we’d be honored to serve you.

The Allstate Layoff: Warnings, Consequences, and the Future

Legacy Broker Reacts To Changing Times

Shifting consumer preferences and behavior……The new insurance clients are tech-savvy, digital-age millennials and the insurance industry needs to adjust to them, not the other way around.

The Future of Employee Benefits & The End of Groupthink

By Bill Rusteberg

Working Americans have long been dependent on benefit decisions made by someone else. That will change and it won’t be long before it does.

Pet Insurance With Super Fast Everything

America’s top-rated insurance for dogs, cats, puppies, and kittens

The Stop-Loss Model is Outdated. We have Designed a Better One.

SOURCE: Zenith Risk Strategies

Zenith is built for advisors and employers who want more than passive underwriting and rising renewals. We combine predictive underwriting, integrated clinical oversight, and transparent economics to deliver better control, clearer performance, and more predictable outcomes.

5 Major Insurers, Vendor Zelis Must Face ‘Repricing’ Antitrust Claims, Judge Rules

The complaint centers on the company’s Established Reimbursement Solution and Reference Based Pricing products.

School District Believes They Get Free Blue Cross TPA Claim Administration Because They Do………

Blue Cross administration fee is a negative $70.82 pepm………..

Your Ultimate Benefits Enrollment Solution

SOURCE: EASE

Open enrollment doesn’t have to be stressful — move your benefits plans to Ease.

Best Benefits Online

Best Benefits Online™ modernizes employee benefits with real choice, and zero admin complexity—all in one platform.

A modern, sensible and common-sense solution for employer sponsored health plans and associations.

The Problem

Payroll teams waste hours fixing deductions, reconciling errors, and dealing with carrier confusion.

The Shift

Move from payroll deduction to direct pay and eliminate complexity while keeping valuable benefits

The Solution

Best Benefits Online™ delivers AI-powered, direct pay benefits with real employee choice

Real Options

Dental, vision, life, disability and more—affordable, guaranteed issue, and easy to enroll

The Outcome

Less admin. More choices = Happier employees. A modern benefit strategy built for employers

Dominated PPOs and the Downfall of ERISA Settlor Discretion

Financial domination is an economic concept referring to an option that is less advantageous than any other available alternative.

Nationwide Mutual Insurance Company Offers RBP Plan

Rising costs demand better solutions and Core Value helps deliver choice, transparency and confidence.