Risk Managers

“The secret sauce was basically having doctors out-of-network, and then delivering surprise medical bills to families who had shown up at an emergency room, loading them up with medical debt”

“Our study suggests that these hospitals actually deliver care at lower prices, instill competition to the hospital market, and expand patient access to hospital care.”

By Matt Henderson

I treated a friend to lunch today. The total for this expense was $33.62. The expense was reasonable for the meal we had and the service received.

By Bill Rusteberg

Forty years of managed care has lead to unsustainable high costs bankrupting the American middle class. Now something amazing is happening.

From: Captive Intelligence

Captives should no longer be considered an ‘alternative market’, with the volume of premium and assets under management carried by self-insurance subsidiaries demanding they be viewed as a market in their own right, according to Paul Phillips, partner and global captive network co-leader at EY.

“Unless hospitals are committing fraud in their reporting to Medicare, their rates cover their costs and profit. To then complain that getting paid more than double that is a “hardship” is laughable. I spent years inside hospitals finances as a consultant. With very few exceptions, they’re rolling in the dough while being incredibly inefficient. It’s remarkable how they’ve managed to perpetuate the narrative of “losing” money on Medicare. Have to hand it to their PR/marketing departments & lobbying arms for pulling that off. The consequences couldn’t be more devastating for the middle class.” – Dave Chase

The Brownsville Independent School District’s self-funded health plan continues to operate in the red. The district contributes +$600 per employee per month but its not enough.

The Brownsville Independent School District, the largest employer south of San Antonio, is seeking competitive health insurance proposals for Plan Year 2024.

“We do not pay Blue Cross to administer our plan at all.”

(WARNING: Excessive head scratching leads to baldness. Reader beware).

By Jeff Bernhard, ReviveHealth CEO

As ReviveHealth continues to expand its collaborations with health institutions nationwide, the glaring reality of America’s physician shortage becomes increasingly evident.

By Darrell Pruitt, DDS

Bad things can happen in paperless practices, Doc………………

If these firms were in charge of your company’s security, you would have fired them after the first robbery. Instead, there’s a robbery occurring daily within your health plan, but these firms all keep their positions as “trusted advisors”.

Ozempic finger is diet drug’s latest side effect — forcing women to spend more money………………..

“For the first time ever, we are opening our doors to all healthcare changemakers to join our annual Summit, RosettaFest, Aug 7-9 in Chicago.” – Dave Chase

Milton Godwin, affectionately known by those of us back in the day as Uncle Miltie, was an aging Houston insurance agent back in the 80’s who specialized in bidding on cities, counties and school districts.

Texas public school districts who have opted out of TRS ActiveCare have been anxiously awaiting legislative action in the hopes the state would gift more monies to help subsidize the cost of their group health plans.

“All industries compete on price and efficiency, but the healthcare industry exists to maximize billings and revenue. They do not compete on price and efficiency. ….. Our vision is to empower the stakeholders of healthcare (doctors, hospitals, and patients) to discover the true cost of care so that they can be the custodians of their own future.” (SOURCE: Health Cost Labs)

Texas Health Insurance Set for Massive Steering and Tiering Shakeup

HB 711 overwhelmingly passed both chambers of the Texas legislature and would allow employers to tier hospitals within a system and steer patients to higher performing centers.

A stand alone benefit option that can be added to any plan giving members a choice between free health care or not so free health care at the point of service.

An employee learned today a medication he urgently needs is not covered by his group health plan.

Working with Mark Cuban Cost Plus Drug Company, PBC, SmithRx will cover YUSIMRY when it is launched in early July 2023. YUSIMRY will be available through the Cost Plus Drugs online mail-order pharmacy for $569.27 plus dispensing and shipping fees, compared to the current price of Humira of $6,922 per carton.

ERISA litigation lawyer Jerry Schlichter has taken to social media to hunt for potential employee plaintiffs for a new brand of fiduciary litigation.……………

The Limitations of PPOs and Their Declining Relevance for Employers: The Rise of TPAs

Ford sues Blue Cross, accusing insurer of price fixing that led to ‘astronomical profits’

Ford Motor Co., which paid $500 million in premiums to BCBS, alleges it was “overcharged” for health insurance in a new lawsuit that’s related to the $2.7 billion antitrust settlement that BCBS and member companies reached in 2020.

“Goodroot is a home for healthcare disruptors. We are founding Goodroot to free the talent and creativity that is currently stifled within our healthcare system.”

Why do the big health insurance carriers need brokers? There are only four majors left in the market, Aetna, Blue Cross, Cigna and United Healthcare. All have fully operational account reps. eager to service business. Each has in-house sales reps to solicit new business. So why are independent brokers necessary? What value do they bring?

Coherus BioSciences to launch Humira biosimilar at 85% discount

By Doug AldeenDoug Aldeen• ERISA Healthcare Attorney and General Counsel

The Texas Hospital District statute requires a determination of ability to pay ( at cost) FIRST prior to initiating any extraordinary collection action (Texas Special District Laws Code 1053.111). In short, the burden is on the not for profit tax supported facility to prove the resources are available (subject to court review) to satisfy any outstanding obligation.

Levelland Banking Center | First Bank and Trust, a division of HTLF Bank (firstbanktexas.com)

At First Bank & Trust, a division of HTLF Bank, decision-making is kept to a local level and bankers are unwaveringly committed to deeply understanding every intricacy of every customer’s financial relationship.

Posted on Linkedin by Dutch Rojas • Educating Patients, Doctors, Self-Insured Employers, Nurses, Benefits Leaders about healthcare. Currently the US has 2x the spend of the modern world. Let’s work towards making it affordable and accessible for all.

A Public  Purchasing Seminar – June 21, 22, 23, 2023

WHO SHOULD TAKE THIS SEMINAR AND WHY……….

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

Every self-funded plan sponsor should put this link on their employee benefits portal.

Since 2019 a number of Texas school districts have left the TRS ActiveCare government health plan. How have they fared since? For example the El Paso ISD didn’t do so well in their first 18 months. Others did better.

Beers family members built a “conglomerate” by selling a Christian alternative to traditional health insurance. They’re now scrambling for cash, even though they received millions in PPP loans that were later forgiven.

By Greg Lamm

A Washington federal judge on Thursday said the insurance industry’s practice of letting an insurer decide whether it is required to provide coverage is “kind of strange” during a hearing involving a teen’s lawsuit seeking coverage from a Premera Blue Cross plan for her yearlong mental health treatment at a residential facility.

The Lone Star State is tops in the nation when it comes to take-home pay, with a $50,000 earner keeping $38,190. As one of the nine states with no income tax, Texas has to share this title with eight other states, but its residents don’t likely mind as they bring home more than residents of other states at the same income level.

Decoding Machine Unveils The Truth Behind Insurance Policies

Insurance policies are notorious for their convoluted language and overwhelming complexity. They often leave policyholders scratching their heads and struggling to comprehend the terms and conditions of coverage. This is intentional.  If you start from the premise that insurance companies do not make money by paying claims, then things start to become clearer.  In this blog post, we explore the reasons behind the incomprehensibility of insurance contracts, examine the impact on policyholders, and provide insights into navigating these perplexing documents.

As prices rise, semaglutide users are turning to online pharmacies for their drugs — even with the FDA issuing safety concerns. As one user puts it: “People are shit out of luck.”

Posted on Linkedin by Scott Haas

“Bring Me Your Sick, Your Poor & Our Tax Savings Will Cure You”

Article Referred By Bob Calvisi

“Years of rising operating profits and cash reserves did not translate to greater charity care across the nation’s nonprofit hospitals, according to a study published this week in Health Affairs.”

“As more and more of these cases make their way through the courts, self-insured health plan administrators charged with properly monitoring and safeguarding plan assets should do so, independent of their TPA’s own reporting.”

Posted on Linkedin by Doug Aldeen Doug Aldeen• ERISA Healthcare Attorney and General Counsel

Charity care should be calculated at cost rather than established billing rates.

Willacy County commissioners approve changes to employee medical insurance

June 07, 2023

BY ALLEN ESSEX
Staff Writer

Willacy County employees will be able to buy certain medicines in Mexico at big savings with a pre-loaded debit card or order them through a Canadian mail-order pharmacy, also with a hefty discount, due to changes approved June 1 by county commissioners.

Allstate, one of the nation’s largest insurance companies, has joined State Farm in deciding to halt sales of property and casualty coverage to new customers in California, saying it’s too pricey to underwrite policies in the state which has seen thousands of natural disasters in recent years.

By Bill Hennessey, M.D. on Linkedin

I Tot I Taw a Kitty Cat – I did – I did!! And the Methodist Hospital TX ER bill was $17,370. Yes, for a cat bite.

Operations Strategist, Paul Wann, Named Chief Operating Officer at HPI

MyHealthGuide Source: HPI, 5/31/2023

Westborough, MA – HPI, a leading national TPA of self-funded benefits, has tapped Paul Wann as their new chief operating officer. Paul will join senior leadership to drive the advancement of operations, automation, and programming. He brings over 30 years of experience in the industry, specializing in numerous areas including system configuration, member care, compliance, and analytics.

If you haven’t been to Morales, Texas you haven’t lived yet. The Morales Store serves up the best hamburgers on the planet.

Attention Health Rosetta Advisors: Here’s an opportunity to bring sanity back to health care finance. This city’s reliance upon the BUCA’s has failed to control costs. Legacy brokers and consultants have failed to deliver desired results too. Doing the same thing over and over again is the definition of…………………..

By Jeff Bernhard – Revive Health

This is an interesting read on wait times for doctor appointments, comparing the United States to other Developed Countries.

For the longest time, most employee benefits programs have consisted of one-size-fits-all group policies for health and life insurance.

TRS ActiveCare, a government health plan for Texas public school districts, has released rates for Plan Year 2023-2024.

Warren Buffett said it all: “GM is a health and benefits company with an auto company attached.” In fact, it spends more on health care than steel, just as Starbucks spends more on health care than coffee beans.

How many American families can afford to pay $31,065 for family health insurance when 90% of working Americans earn less than $100,000 per year and 46% of working Americans earn less than $30,000 per year. After mortgage and car payments, rent, food, gasoline, clothing, beer & fajitas there is no money left for health insurance.

Dino Chavez, a Brownsville, Texas taxpayer, does an excellent job educating the Brownsville Independent School District’s (BISD) Board of Trustees in under five minutes on the power of managed care contracts and offers a common sense solution.

• State Farm General Insurance Company on Friday announced that it will stop accepting new homeowners insurance applications in California.
• The company cited “rapidly growing” catastrophe risks like wildfires, “historic increases” in construction costs and a challenging reinsurance market.
• “We take seriously our responsibility to manage risk,” the company said in a release.

We are now authorized to quote and bind Workers Compensation Insurance on behalf of Texas Mutual. In addition to Workers Compensation, HB 3752 authorizes Texas Mutual to establish and market a very different group medical program for employer groups of <250 employee lives.

Profiteering Against the Public Interest: Privatization of Health Care by Unitedhealth Group

UHC was just smarter and recognized the direction of the market faster than everyone else i.e. privatize profit and socialize risk…

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. 

I knew little of my father’s participation in WW2 until after he died. Unlike veterans of today his generation didn’t talk much about it. Their quiet pride was enough, understood by all. The following recounts the Battle of Hatten in which my father was a participant. – Bill Rusteberg

Publicly filed, 5500 forms provide a wealth of information including disclosed (as opposed to undisclosed) insurance broker commissions.

Gert-Jan Oskam was living in China in 2011 when he was in a motorcycle accident that left him paralyzed from the hips down. Now, with a combination of devices, scientists have given him control over his lower body again.

“Hidden” vendors can account for a significant volume of day-to-day transactions, accessing and storing vast amounts of plan participants’ personally identifiable information(“PII”) and personal health information (“PHI”). The delegation tactics used by employee benefit plan service providers place a premium on third-party risk management (“TPRM”) as a strategy.

Wait For Me Daddy!

“That’s probably the last time we were together as a nuclear family, as they put it today,” said Bernard in a recent telephone interview from his home. “We were never together again as a family after that moment.” – Warren “Whitey” Bernard (Blond headed boy in the picture)

TRS ActiveCare is meeting next week to discuss new benefit changes and rates for the government’s health plan for Texas school districts. Will rates go down? Will benefits increase?

File this under “You Can’t Make This Stuff Up”

TRS ActiveCare officials are set to announce benefit changes and new rates next week. The battle to win Texas public school business will be off and running as districts gear up for school year 2023-2024.

By Bill Rusteberg

When things become political simple decisions benefiting everyone can become hard to make. A circular firing squad kills good ideas swiftly and effectively through “self destructive internal conflict and mutual recriminations.”

While it is still relatively early in the legislative process, enactment of provisions in the current iteration of S. 1339 would pose significant impacts to entities across the prescription drug distribution chain………………

Yesterday Rhea Campbell, Co-founder ImagineMd sent a note that caught my interest:

“We are using QR codes to load plan funds to obtain cash pay pricing. We’re about to go live with a plan on 7/1 that has this option. We trigger the loading when we want to refer for imaging or mammogram for example. Cash pay for these services is slightly less than RBP so we’ll drive even more cost savings.”

What’s the best Medicare pricing benchmark plan sponsors should use? Is it 100%, 120%, 150% or 200% of Medicare? Is there a material difference in balance billing issues between these tiers? The answer may surprise you.

The over-arching truth – government has been much more effective than private insurers…….

Below is part of a contract we reviewed recently. The Agreement begins:

“The best work comes out of great relationships. Honesty, respect and gratitude are the keys to a great relationship and therefore we have an interest in treating each other with these values at all times. As much as legal documents are important, what truly binds us is our drive to do great work with great people and to develop a relationship of mutual respect and trust.”