Uncategorized – Page 9 – Risk Managers

Balance Billing & Provider Push Back

Adam Russo of the Phia Group explains balance billing strategies

Benchmarking Claims Off Medicaid Fee Schedule

By Bill Rusteberg

There’s more than one way to skin a cat……………..

Reference Based Pricing plans typically benchmark claims against the Medicare fee schedule. Why not benchmark off the Medicaid fee schedule too?

Actuarial Warfare: How Seven Insurance Letters Closed the World’s Most Critical Chokepoint and Why Markets Are Mispricing Duration by 300%

London treaty reinsurers, confronting unlimited tail coverage, pull capacity………….

Allied National’s Solution For Tight Budgeted Employers Seeking Relief From Punishing Govt. Mandates

A Dental Plan That Beats A Poke In The Eye

Brownsville ISD Considers Early Termination of TPA Agreement

By Molly Mulebriar

The Brownsville ISD has a history of suing their TPA going back years. Pilot Life Insurance Company, Group & Pension Administrators, HealthSmart………….Will United HealthCare be next?

The Growth of Claims Audits

Written by Tim Rieger, Vice President, Sales, Consulting & Education

A growing trend among self-funded medical plans is the increased focus on claims audits. Unlike dependent audits, claims audits are more comprehensive and time-consuming. Employers are increasingly recognizing their fiduciary duty to act in their employees’ best interests, making claims audits an essential part of meeting these responsibilities.

5 Best Workers Compensation Insurance (2026)

SOURCE: Best Business Insurance Companies of 2026

Compare the leading workers compensation insurance providers and agencies of 2026. We reviewed and ranked based on ease of the policy purchasing process, industry accreditations, customer service capabilities, and past customer reviews.

A Common and Costly Oversight: The Importance of a Written Section 125 Plan

A Common and Costly Oversight: The Importance of a Written Section 125 Plan

The Price of Babyhood In Carizzo Springs, Texas

SOURCE: Dimmit Regional Hospital

Blue Cross believes babies are worth more while United HealthCare believes they’re worth less and mothers don’t care because their babies are priceless………….

The Story Behind ‘Lunch Atop A Skyscraper

“Lunch Atop A Skyscraper” captured 11 workers lunching amid construction of New York’s Rockefeller Center on September 20, 1932 — but there’s much more to the story.

For nearly a century, the iconic photograph “Lunch Atop A Skyscraper” has been uniquely evocative of everything from New York City to the Great Depression to America itself. The photo features 11 construction workers casually having lunch while dangling 850 feet above the Big Apple one September day in 1932. But while its imagery is legendary, few know the remarkable story behind it.

Sturgis, Michigan Has 10,000 Residents

By Dutch Rojas – Visit my website

Sturgis, Michigan has 10,000 residents. One company based there billed $826 million in Medicaid personal care services between 2018 and 2024.

For context: to bill $826 million in 15-minute increments at Medicaid rates, you would need to document and submit claims for a number of service hours that, divided by the local population, implies every man, woman, and child in Sturgis received personal care assistance for roughly 2.3 hours per day, every day, for six years.

Texas Penal Code §32.45 — Misapplication of Fiduciary Property

A person commits an offense if he intentionally, knowingly, or recklessly misapplies property he holds as a fiduciary or property of a financial institution in a manner that involves substantial risk of loss to the owner of the property or to a person for whose benefit the property is held.

Aldeen’s Sunday Morning Bathroom Read – The Oregan Potato Company Caper

“The Oregon Potato Company Caper exposes, once again, the nasty underworld of health insurance brokerage” – Bill Rusteberg

GoodRx to Expand Employer-Sponsored Access to Zepbound® KwikPen®

SOURCE: GoodRx – Mar. 6, 2026

GoodRx Employer Direct enables self-insured employers to subsidize the $449 Lilly Employer Connect medication price for Zepbound KwikPen to reduce employee out-of-pocket costs

Hospital Financial Statements, Clinical, and Quality Metrics

Analyze financial statements and clinical metrics of every hospital in the U.S. Review balance sheets, debts and ratios, cost centers, and other financial data. Look up hospital inpatient surgeries, ER visits, average daily censuses, total acute days, and other clinical information.

Health Insurance Costs by U.S. State in 2026

Health insurance costs are rising across the United States in 2026, as enhanced Affordable Care Act (ACA) subsidies expire and insurers raise premiums to keep up with higher healthcare costs.

This graphic shows the average health insurance cost on the ACA marketplace in 2026, based on data from ValuePenguin.

Lilly Lowers Price of Zepbound®

*Regular prices (per month) when not purchased via the Zepbound Self-Pay Journey Program: $599 for 7.5 mg, $699 for 10 mg, $849 for 12.5 mg, $1,049 for 15 mg.

Lilly continues efforts to expand access for people living with obesity by lowering the price of Zepbound single-dose vials

Growing Number of Legacy Health Insurance Brokers Hate The Business

A dying breed of yesterday wonders hoping to stay relevant……….

By Bill Rusteberg

Ask just about any legacy health insurance broker if they like what they do and you will be hard pressed to find one who does. But few will admit it. It’s not cool.

The Secret To ICHRAs

“The standard broad Exchange/IFP network has prices roughly 50% below the broad PPO.”

Curative Insurance Company

In this 11 minute video by Fred, co-founder of Austin based Curative Insurance Company, discloses the company’s secret sauce to control rising health care costs and it’s the opposite of what you would expect.

Trump says US to provide insurance for Persian Gulf maritime trade

SOURCE: IRAN International

President Donald Trump said on Tuesday he had ordered the United States Development Finance Corporation to provide political risk insurance and guarantees for maritime trade traveling through the Persian Gulf.

Dr. Mandrake Curvy Is A Litte Strange

Patient talks about his in-network primary care physician who employs unusual healing methods for the sniffles…………….

Aldeen’s Sunday Morning Bathroom Read (“Send Lawyers, Guns and Money”)

The Barbarians are at the gate with unbridled avarice ready to plunder and pillage.

By Doug Aldeen

Anthem alleges in a recent lawsuit that providers and their third-party biller ( HaloMD) are abusing the No Surprises Act arbitration process to receive higher out-of-network payments in violation of the federal Racketeer Influenced and Corrupt Organizations (“RICO”) Act, the Employee Retirement Income Security Act, and California’s Unfair Competition Law, among other legal requirements.

Reference Based Pricing Spreads Happiness Across The USA

Critical Thinking Exercise Sets Aging Hospital Administrators On Fire

By Bill Rusteberg

This is a must read for hospital administrators over the age of 50 whose diminishing critical thinking skills have skewed reality into fiction at the expense of common sense, reason and logic.

What’s Your Data Worth?

By Bill Rusteberg

Selling information is big business. Take hospital pricing for example. Government diktats mandate hospitals must provide pricing transparency in the form of “Machine Readable Files.”

Price Transparency Is Here

Stop Negotiating. Bring the Facts.

Understand every contracted rate and claim in your market. Level the playing field and turn negotiations into partnerships

Buy Workers Compensation Insurance Online In 5 Minutes

Save up to 20% on your business insurance. Get a quote and get covered online in minutes.

A Third of Employers Can’t Access Medical Claims Data from Vendors, Survey Finds

Many employers are struggling to access their medical claims data from vendors. However, those who do have access are more likely to implement strategies to combat healthcare costs.

Plan Sponsors Beware! Dependent Coverage Is Your Fifth Column

By Bill Rusteberg

There exists among almost every group health insurance plan a Fifth Column, a small group of insiders whose quiet activities work against the principal of the greatest good for the greatest number.

Is Your Group Plan Affordable?

Want to know if the government thinks your group health insurance is affordable or have you figured that out yourself? Has your family coverage cost become like a second mortgage?

Largest Risk Pool In Texas Covers 4.2 Million Texans

58% of risk pool members pay less than $10 per month……………

Novo Nordisk to slash Ozempic and Wegovy list prices by up to 50% for 2027

Battling to regain its market share over rival Eli Lilly, Novo Nordisk announced Tuesday that it will reduce the list prices of its popular weight loss drug Wegovy and diabetes drugs Ozempic and Rybelsus by up to half starting in 2027.

Canada is Killing People in Assisted Suicide the Same Day They Request It

International | Right to Life UK | Feb 20, 2026 | 2:53PM | Ottawa, Canada

People in Canada are having their lives ended by assisted dying on the same day that requests are made, adding to fears that wrongful deaths may be occurring.

THE IDR BLUES

By Craid Gottwalls

The No Surprises Act was designed to protect patients from unexpected medical bills. That is a noble goal. The mechanism created to settle those out-of-network claims, known as Independent Dispute Resolution, is having a very different effect. It has become an inflationary engine for the entire healthcare system.

More than 60% of UHC’s Physician Group E/M Contracts Are Below Medicare.

By Josh Nakka | Healthcare Market Intelligence – Visit my website

More than 60% of UHC’s physician group E/M contracts are below Medicare.

80-90% Of Health Plan Members Pay Cash For Health Care

It it’s true 80% to 90% of people never hit their deductible that means they’re paying for 100% of their care……..in cash.

Amazing Alternative To High Cost Group Family Coverage

Is Your Family Health Insurance Too Expensive? Go here & we’ll calculate cost saving options that may stun you…….and government subsidies you may qualify for. “It’s always in your best interest to be aware of quality options”

4.2 million Texans enrolled in ACA Marketplace plans for 2026 with 97% receiving premium tax credits.

Cash Pay Health Plans Made Simple

Hey Doc! What’s your best price? I’ve got cash!…………………..It’s your choice!”

Say Goodbye to ACA Reporting Headaches

Dreading another reporting season? WEX can help.

San Felipe Del Rio ISD Goes from Self-Insured to Fully Insured

“San Felipe Del Rio CISD believes that access to quality health care for its employees and their families is of great importance.”

Aldeen’s Sunday Morning Bathroom Read – NSA Edtion

“Overnight, the government created a $5 billion market, sanctioned employer balance billing (with an 83% success rate for providers) and gave a 3x-4x pay raise to folks subject to the NSA/IDR regulatory framework. The NSA/IDR process is not a way to occasionally resolve reimbursement disputes. It is a business model.”

McAllen ISD Employee Saves $8,796 On Family Health Insurance

By Molly Mulebriar

Jorge is a devoted employee of the McAllen Independent School District in deep South Texas and like many other working Americans he struggles to pay for family health insurance for his wife and two children. The district offers a generous health insurance package but his cost to add his family is a hair above 9.2% of his annual household income. It’s a second mortgage he can’t afford.

Hammurabi, a Division of Xchange Benefits, Unveils AI Platform That Revolutionizes Medical Stop Loss Underwriting

MyHealthGuide Source: Xchange Benefits, 02/18/2026

ARMONK, NY — Hammurabi, a division of accident and health managing general underwriter Xchange Benefits LLC, a subsidiary of Octave Specialty Group, Inc. (NYSE: OSG), has unveiled an artificial intelligence platform that fundamentally transforms how medical stop loss insurance is underwritten, replacing a traditionally labor-intensive process with near-instant risk prediction and pricing accuracy.

The Greatest Homerun Ever: Bill Mazeroski 1960 Walkoff Homerun

Bill Mazeroski dies at 89…………….

Brownsville ISD Employee Saves $7,597 On Family Health Insurance

By Molly Mulebrar

Jorge is a devoted employee of the Brownsville Independent School District in deep South Texas and like many other working Americans he struggles to pay for family health insurance for his wife and two children. The district offers a generous health insurance package but his cost to add his family is a hair above 9.12% of his annual household income. It’s a second mortgage he can’t afford.

Dental: The Coverage Agents Love to Hate (But Shouldn’t)

We get solicitations to sell various insurance products and services every day. Our mailbox receives more than one a day. We enjoy reading the “Pitch” designed to grab attention. You gotta love these marketing efforts. This is the latest……………….and it’s a great “Pitch.”

Medicash

Cash pay health plan strategies in the United States is becoming popular. But did you know the scheme has been in practice for decades across the pond? The English have been decades ahead of us.

Are You Fed Up & Not Going To Take It Anymore?

By Molly Mulebriar

Family health insurance premium is too damn high! Family coverage through employer sponsored health plans is out of reach for many working Americans.

HIGH OR LOW DEDUCTIBLE PLANS?

Keep your deductibles high when you’re forced into the fully insured viper’s den, and lower the deductibles as much as your budget will allow when you self-fund.

Stripe

Financial infrastructure for the future of insurance………..

How a Cash-Pay, Reimbursement Model Works (And Why It Can Save You Thousands)

Start Health is a reimbursement policy (Indemnity Plan), not traditional insurance. We reimburse fixed amounts based on your care, which gives you the freedom to choose providers and control costs. As the only reimbursement plan that’s designed to be HSA-eligible, you can also pay tax-free with your Start HSA Card, combining flexibility, transparency, and savings.

Proposed PBM Fee Disclosure Regulations – A Major Gamechanger

The DOL’s proposed regulations establish new disclosure and audit requirements for “covered service providers” that enter into contracts or arrangements with self-insured group health plans and reasonably expect to receive $1,000 or more in compensation in connection with providing pharmacy benefit management services or providing advice, recommendations, or referrals regarding the provision of such services.

Generic Drug Pricing: What’s Below The Surface

By Ginny Crisp

Generic drugs cost pennies to make. So why does your plan sometimes pay dollars?

ICHRA – Medicare: Here’s A Plan You’ve Never Heard Of Until Now

By Marcus Greene – Founder, Saidi Health

After 15+ years in this industry, I’ve learned something important: most of the biggest opportunities in insurance don’t come from new products — they come from fixing problems employers didn’t even know they had.

Round Rock ISD Opens New Employee Health Clinic To Combat Rising Insurance Costs

by: Kevin Baskar Feb 17, 2026 – Article Referred By Brent Evans

ROUND ROCK, Texas (KXAN) — Round Rock ISD (RRISD) is opening a new employee health center for the district’s staff and family members amid rising health care costs.

Drop The Middlemen – Choose Direct

SOURCE: Directhealthplan.com

Direct Health Plan is a complete solution for self-funded employers in need of an employer health plan.

Operates as a stand‑alone plan or integrates seamlessly with multi‑plan offerings; built for your control and flexibility.
Serves as a chassis for health systems, DPC/concierge practices, advisors, and the wider health solutions industry, a foundation for innovation. Let’s build.
A fully fee‑based model — no shared savings, hidden rebates, or commissions.

Distribution: Direct to employer and select broker partners across the United States.

TRS-ActiveCare: What the February 12, 2026 Board Materials Actually Reveal

“TRS-ActiveCare is not financially self-sustaining and survives only through recurring taxpayer subsidy and ongoing cost shifting to employees.”

TRS ActiveCare Members Struggle to Afford Family Coverage

Joe finally gets the bass boat he’s always wanted but could never afford until now………..

SOURCE: EZaccessMD

EZaccessMD has an average client utilization rate of 70% (and climbing). That’s more than 10x the average utilization rate for traditional telemedicine.

TRS ActiveCare Renews With Blue Cross

Rapid growth government health plan for Texas public school districts renews Blue Cross Contract – More districts believe the Grass Is Not Greener On The Other Side.

AG Ken Paxton Backs Ivermectin Champion’s Fight Against Texas Medical Board

The board reprimanded Dr. Mary Bowden last year after she prescribed ivermectin to a patient at a Fort Worth hospital during the height of the pandemic.

The Great Escape

The Institutional Broker/PBM Shadow Economy Hit with a Massive Spotlight

Wall Street and Private Equity are Sweating…………

Common Sense Alternative To High Cost Group Dependent Coverage

Go Here For Benefit & Enrollment Information (1out of 3 people pay under $30/month)

Attorney General Ken Paxton Demands Information from Blue Cross Blue Shield of Texas and Conduent as Part of Investigation into Largest Data Breach in U.S. History

Article Referred By Lori Ramos

Attorney General Ken Paxton issued Civil Investigative Demands (“CIDs”) to Blue Cross Blue Shield of Texas (“BCBS”) and Conduent Business Services LLC (“Conduent”), demanding documents and information pertinent to the investigation of the Conduent data breach that exposed the sensitive personal data of approximately four million Texans.

Kimberly Has A Question………

“Average cash price without insurance= $9.96. Express Scripts Mail Order price= $235.32.”

What Traditional Group Insurance Brokers Won’t Tell You

Employer Sponsored Group Dependent Coverage Is No Longer Relevant

“For a lot of families, $15–$25K for dependent coverage isn’t “benefits” anymore — it’s a second mortgage. When ACA marketplace options can deliver compliant coverage with subsidies that drop costs to a few hundred dollars (or less), it’s hard to justify forcing everyone into the group plan just because “that’s how we’ve always done it.”

The Blank Check Problem

By Pearly Chen

Most people don’t realize that the standard hospital consent forms in ER could commit you to paying full billed charges from the Chargemaster, where prices can be 500% to 1000% higher than what the government or insurers actually pay for the same services.

Tired of Waiting For Renewal Surprises? Meet Your New Best Friend

Want an indication of what your renewal will look like before your broker does? Tired of waiting for last minute renewals giving you no time to shop around for a better deal? Can’t afford the luxury of your own in-house actuary? No worries, meet Your New Best Friend!

Will AI Take Over Actuary Jobs? 2025 Future of Actuaries

AI transforms actuarial work, not eliminates it. 22% growth projected through 2034 as AI automates tasks while expanding demand for expertise.

+90,000 In 24 Hours

Why has this article received so much attention? It’s now 96,817 and growing still.

Compare Quotes In 60 Seconds & Cut Your Insurance Bill In Half

SOURCE: INSURIFY

Why compare with Insurify?Insurify delivers serious savings with no hidden fees and no catch. We’ve already helped millions of people find exclusive rates and discounts.

Employer Sponsored Group Dependent Coverage Is No Longer Relevant

Families cannot afford dependent coverage costing as much as $15,000-$25,000 per year through employer sponsored group health insurance plans. There’s a solution to this madness.

Texas Historical Commission 2026 Conference

Texas’ premier historic preservation and heritage tourism conference—presented by the Friends of the Texas Historical Commission in partnership with Phoenix 1 Restoration and Construction, LLC—is shaping up to be our most exciting year yet. Register before the final price increase on March 6.