Risk Managers

Removing the third person from the room is every physician’s dream. For DPC doctors the dream has become true.

In 2012, Insys hired a new sales executive: Sunrise Lee, a Florida escort service manager and former strip club dancer with no academic degree, according to Guzman’s complaint. Burlakoff allegedly defended the decision, claiming, “Doctors really enjoyed spending time with her and found Sunrise to be a great listener.” He added, “She’s more of a closer.”

One critical Benchmark for a healthplan is Medical Expense Per Employee Per Year (PEPY). Our #FairCostHealthPlan is $4,428 PEPY while the national average is $12,125 (Truven Medstat) – 64% below the nat’l average.

“Why should a plan sponsor negotiate a hospital contract when plan members do that already?” Bill Rusteberg

Eli Lilly is slashing prices on its most-prescribed insulins and capping out-of-pocket costs for patients amid pressure from consumers and the Biden administration. After years of price hikes on insulin, Lilly on Wednesday said people with diabetes would see 70% reductions on its most common versions.

National Care Dental offers PPO plans underwritten by Met Life and Nationwide under one contract.  You will have a unique enrollment portal and network for each carrier, however a shared back office to view your book of business and commissions.  Great brand names to promote!

Employees Earn $4,128 Pay Raise Plus Free or Almost Free Health Insurance……..

Mueller Manufacturing Company decided there was a better way to provide their 300 employees with free or almost free health insurance while gifting them a raise at the same time.

Your groups could be saving 43% on health benefits by utilizing an ICHRA.

Holy Smoke! I’m in the wrong business………………..

Blue Cross ASO Agreement with a Florida school district is posted on the world wide web. Now that it’s posted here let’s see how long it stays in the public domain.

To estrange themselves further from their calling, doctors bow as never before to the state and the corporation.

An ICHRA is by definition a group health plan providing a superior method of health care finance for plan sponsors………. for a lot of reasons.

Within 24 hours of posting a link to a copy of Texas A&M’s BCBS ASO Agreement it has been removed from the internet. The Cone of Silence continues………………..

Suit Against Anthem Exposes Conflict Over Health Claims Data

Article Referred By C. Smith, M.D.

An employee health plan sues its health insurance administrator for refusing to turn over claims data that would allow the employer to verify the accuracy of charges against its self-funded health insurance plan. Medical supply vendor Owens & Minor says Anthem Blue Cross and Blue Shield has refused to provide it with claims data since 2021 as required by federal law. Anthem says its claims data involves proprietary arrangements that it doesn’t want to make public. Several similar lawsuits have been settled out of court, with details hidden behind non-disclosure agreements.

The Texas Hospital Association has concerns, including that providing itemized invoices for every patient’s bill would be costly and time-consuming. 

Doug Aldeen• ERISA Healthcare Attorney and General Counsel

The state of Connecticut plans to erase $2 billion in medical debt for its residents.
Caveat Emptor and Key Inquiries: 1) Determine the original price of the medical services and 2) How many individuals were otherwise eligible for financial assistance? Perhaps $20mm is still overpaying these hospitals…

“No one wakes up and says, ‘I want to go to the hospital,'” said Ayesha Clarke, interim director of the Hartford-based nonprofit Health Equity Solutions. “However, when it happens, seeking care should not result in a lifetime of financial hardship.

It’s been our experience over the years most Plan Sponsors never read their TPA administrative agreements. As an example, some years ago a client approved their ASO agreement without first allowing us to review it as was required under our management agreement. They screwed themselves and I had to tell them they screwed themselves. Sugar coating has never been our style.

The Mercedes Independent School District can’t decide what to do…………….

Article Referred By Dan Meylan

LOUISVILLE, Ky.–(BUSINESS WIRE)– Humana Inc. (NYSE: HUM) today announced that it will be exiting the Employer Group Commercial Medical Products business, which includes all fully insured, self-funded and Federal Employee Health Benefit medical plans, as well as associated wellness and rewards programs.

“The market is going there,” said Larry Van Horn, associate professor of management, law, and health policy and executive director of health affairs at Vanderbilt University. “You’ve got direct primary care, you’ve got physicians going and moving into cash pay. You’re gonna have to sit there at some point and say, ‘Wait a minute, they’re taking my business.'”

“Employers who are leveraging these cash pay strategies are saving so much money that they can offer healthcare benefits at no cost to the employee, no employee premiums and no out-of-pocket expenses like copays and deductibles.

We’ve experienced record growth over the past 24 months, and this has produced opportunities for us to better scale our business.  

Patient refuses to pay $75 for a two minute doctor visit. If more patients questioned what things cost before receiving services there would be no such thing as a balance bill. And it would be a good first step towards solving the high cost of health care in this country.

“I’m a little confused, how long have you been dead?” I asked in an open ended way.……………………..“Oh well now. A while. It must be a while.” The gentleman replied, with hestitation.

During the 17-hour operation, surgeons removed Andy’s diseased organs. He then received the following deceased donor’s organs all together and at the same time: liver, stomach, pancreas and duodenum (pancreaticoduodenal complex), spleen, small intestine and right colon.

This is why we don’t bid on insurance consulting services………………..

Cash pay health plans, funded through employer sponsored plan assets, are the future of group health care benefits for working Americans. Savings over insurance based health care are 50% and more.

“I just do not see the value of insurance if essentially I’m paying four times more to use it on top of paying a monthly premium and on top of marching towards a deductible,” Edwards said. “It is no longer a good value proposition.”

The way it works is that Sidecar issues its insured members what’s basically a debit card that they use to pay for care, prescriptions, and consultations directly. The money comes from Sidecar’s claims accounts and is paid directly to doctors.

Here at Zeihan On Geopolitics we select a single charity to sponsor. We have two criteria:

Retrospective underwriting can be a powerful marketing strategy. It has been used in the past with good success – write new business with scant regard of traditional underwriting parameters. In nine months you know what your picked up. At 12 months you run off the dogs and keep the rest.

Will the state continue to make up the shortfall for the TRS ActiveCare government health plan? Commercial carriers operating in the real world competing for Texas school business don’t enjoy that advantage. So how can the commercial carriers and third party administers compete? Sneaky underwriting?

So far there have been over 250 insurance related bills introduced in this Texas legislative session. We are seeing quite a few bills that will impact the growing market trend towards health care pricing transparency. Many of these bills will benefit Cash Pay Centric Health Plans.

If passed this legislative session, Texas HB 711 will forever change manage care contracts. Can you hear the BUCA posse thundering towards the upcoming sub-committee hearing…….?

Texas HB 633, if passed during this year’s legislative session, will provide broad application for Cash Pay Centric Health Plans, a growing market phenomenon. Cash pay health plans are the future of health care finance.

Texas A&M offers a medication assistance program for uninsured and underinsured Texans to obtain affordable prescription drugs through pharmaceutical patient assistance programs and foundation money.

TEACHER RETIREMENT SYSTEM OF TEXAS MEETING BOARD OF TRUSTEES

AGENDA February 16, 2023 – 12:00 p.m.

Discuss and consider selecting a pharmacy benefit administrator(s) (PBMs) to improve and enhance financial performance and services for public education employers, employees, retirees, and their families participating in the TRS-Care Standard, TRS-Care Part D (solicited as TRS-Care Indirect EGWP with Wrap PDPs), and TRS-ActiveCare……..

The following article describes the plight of one third of the population of Oklahoma who are on target to lose their Medicaid health insurance this year. The article does not mention 100% of those affected by the Medicaid cut will qualify for free hospital care under IRC 501r…………….and guess who is going to pay for all of this……………

NP practice owners assume the liability exposures of their practice, including those of their employees and independent contractors…………….evolving state licensure laws permitting NPs to practice more independently have contributed to the increase in percent and severity of claims.

Article Referred By Brent Evans – Sundown, Texas

West Texans are fiercely independent. There’s nothing a West Texan can’t figure out. When something breaks they don’t call for help, they fix it themselves. If they don’t know how, they figure it out. This fellow is no exception.

Pottstown’s superintendent Stephen Rodriguez said he was thrilled by the decision. “This decision is validation that our concerns with Tower Health were appropriate. They did not meet the measure of the law and should be paying their fair share of taxes and I look forward to them paying up.”

By Bill Rusteberg

“Do we have a Francisco Ybarra working for us?” asked the Sister. “Yes, he’s our grounds keeper” replied Maria in HR. “Ok, tell him Friday is his last day!” said the Sister of Charity……..“Now about this renewal offer……”

Texas Bill Would Require Law Enforcement to Carry Liability Insurance

A bill introduced last week by a Texas lawmaker would require law enforcement officers in the state to carry liability insurance as a condition of employment.

Professional Governmental Underwriters, Inc. is a full-service risk management company dedicated to assisting public, educational and non-profit entities in the management of their professional liability exposures.  Current operations are dedicated to underwriting and marketing Public Officials Liability, Law Enforcement Liability and Educators Liability insurance.

We are dedicated to providing state-of-the-art professional underwriting management and loss control advisory services on behalf of our designated carriers. We operate through a network of professional producers who seek specialized services for their public, educational and non-profit entity clients.

By Bill Rusteberg

A self-funded plan sponsor has direct agreements with several San Antonio hospital systems. These direct agreements are a straight, flat rated Medicare based fee schedule without the usual managed care outliers such as escalator clauses, stop loss provisions, etc.

Montana’s Tax-Exempt Hospitals Oppose Increased Oversight by State Officials

More than half of acute care hospitals in the United States are nonprofit hospitals, which must record community benefits — such as covering a patient’s bill or offering mental health services at a loss — with the IRS for their tax exemptions. But federal rules around how hospitals tally charitable acts are broad, with oversight lacking. Pressure for more transparency has mounted as about 6 in 10 adults in the U.S. with household incomes below $40,000 have medical debt, and altogether Americans owe an estimated $195 billion or more.

UHC Tacitly Admits Not All Providers Cost The Same………………………

How to save money on health care? First, identify all the cheap providers. Second, from that list pick out the ones that graduated at the top of their class. Then bundle them all together and brand them the Gold Star Value Network.

In Turkey, compulsory earthquake insurance is offered to the public via a catastrophe insurance pool, which has a claims paying capacity of nearly $2.5 billion, based on its 2021 reinsurance renewal.

Headquartered in St. Louis, Missouri, The Defense Collaborative is a fresh take on risk / claims / liability / insurance / defense. It is a collaborative networking and education platform facilitating the creation of relationships through networking events, CLE/CE approved seminars and non-CLE/CE approved seminars. Fun culture. Safe environment to gain feedback. No gains other than to facilitate meaningful connections through education/scenarios.

“A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose………….”

When comparing insurance costs, using premiums does not present a realistic comparison; use rates. Divide the premium by the exposure (values, number of vehicles, cost new of insured vehicles, number of students).

By Bill Rusteberg

Lasers have been unfairly treated and it’s time to show a little respect!

The Transparency in Coverage Final Rule and Texas House Bill 2090 require disclosure of the negotiated rates with in-network providers and the historic allowed amounts paid to out-of-network providers, for all health plans available to employers.  Files containing this information for the plans covered are published on this page.

Murray was a most amazing character and ended up selling me life insurance….. at 27 years old!

Brownsville ISD board members debate the value of their health insurance broker at a Brownsville ISD Insurance Committee Workshop on May 13, 2020.

There is a difference between managing risk and servicing risk. Legacy health insurance brokers provide the later. New era health insurance brokers provide the former leaving TPA’s to service the risk.

By Josh Butler

I’ve got a brilliant idea….What is it? Let’s make buying prescriptions sooo complicated, no one will ever be able to understand it….

“Like a good neighbor, State Farm is there – and here and in my bed with my wife!”

Tesla dispute – top auto insurers writing off rather than repairing crashed Tesla EVs

by Mary Or 31 Jan 2023

Auto insurers have been writing off crashed Tesla EVs and sending them to salvage auctions instead, deeming many too expensive to repair.

(1) Crank up the printing presses and gift more money to health insurance companies to pay for out of control health care costs and (2) Gift stolen wages from working class Hyphenated-Americans to health insurance companies to pay for out of control health care costs.

“Bill provisions include making enhanced subsidies (OTHER PEOPLE’S MONEY) for Affordable Care Act Health Insurance Marketplace coverage, extended through 2025 in the Inflation Reduction Act, permanent; designating the second-lowest-cost Gold plan the benchmark plan upon which premium subsidies (OTHER PEOPLE’S MONEY) are based; and increasing the value of cost-sharing reduction (CSR) assistance for those with income between 100 and 250 percent of FPL (Federal Poverty Level) while expanding eligibility for CSR assistance to people with income up to 400 percent of FPL.”

Hiding Behind A Logo is a traditional American health care finance method of controlling the irrational correlation between cost of services and goods to end-user pricing while protecting ever increasing revenue streams from public display at the same time.

January 28, 2023

Barb Teron, a book buyer in Brook Park, Ohio, plans to delay her retirement because she is worried about Humira’s cost. Ms. Teron, who takes Humira for Crohn’s disease and colitis, has never had to pay more than $5 for a refill of the drug because her employer’s insurance plan picks up most of the tab. The cost, according to a pharmacy app on Ms. Teron’s phone, was $88,766 in the past year.

By Justin Nutt

A study in the U.S.A found that the most productive age in human life is between 60-70 years of age.

By Eric Kolenich

Hospitals are now required by federal law to publish the prices of mammograms, CT scans and hundreds of other procedures.

Medicare pays through the nose for services rendered by frugal doctor……….

“Daddy, who do you think you are, a doctor or an insurance company? Since insurance companies have always paid you and not your patients, doesn’t that mean you’re an agent of the insurance company?”

“Not any more son. Screw insurance companies! I work for my patients now” Dr. Doogood chortles.

Cash Pay Centric Health Plans are becoming a growing market trend, catching the attention of plan sponsors and government officials. The strategy is based on common sense, reason and logic applied to health care, something long missing from American health care financing.

Jack Sullivan who murdered John Bradbury, a railroad officer, during a gun fight, is seen smoking a cigar a few moments before he took his last breath in the lethal gas execution chamber at the state prison on May 17, 1936 in Florence, Arizona. / AFP PHOTO / ACME / – (Photo credit should read -/AFP via Getty Images)

“It seemed like the theme park ride vehicles were getting smaller, and I was getting bigger…..”

By Bill Rusteberg

Years ago a hedge fund operator called seeking information on Reference Based Pricing, a nascent but growing market trend at the time. He continued calling over the next six months to which I was happy to share my experience, both good and bad, with Reference Based Pricing.