Risk Managers – Page 45 – Thought Leadership on Health Insurance

Let’s Play The % Of Savings Game (But I Make Up The Rules)

Lawsuit accuses administrator of underpaying benefits for out-of-network care for self-funded plans

Reference Based Pricing Spreads Happiness Across The USA

Average PPO allowed amount is 250% of Medicare. Hospitals cash PPO checks and are happy.

Average Reference Based Pricing (RBP) allowed amount is 150% of Medicare. Hospitals cash RBP checks and are not happy.

RBP + CPO + DPC + HFAP + SDRD + CR = Affordable & Better Health Care

Reference-based pricing is a different way of doing healthcare. Here’s how to get it right

By Christian YantornoDecember 28, 2022, 9:00 a.m. EST3 Min Read

Reference-based pricing entered the conversation a few years ago as a solution and response to unsustainable healthcare price increases, and the model is still gaining traction among self-funded organizations. It is becoming increasingly popular as employers embrace an alternative solution that will help them cut costs.

Amarillo Gunslinger: “Have Gun, Will Travel”

Retail vs Wholesale

If your plan is a PPO you are overpaying for health care by 100% and more. Of course you have no idea if that’s true because you’ve been lied to for years on end. And, you have little ability to find the truth because PPO contracts are proprietary, secret contracts of adhesion.

It’s A Bird! It’s A Plane! It’s, It’s Kelsey Care!

Medical Stop Loss Captives On Course For 25% Market Share

“MSL (Medical Stop Loss) captives that employ sound risk selection (membership) guidelines and have a platform based on medical cost and risk reduction initiatives will continue to outperform the traditional stop-loss market and deliver the best results for their members.”

95% of Plan Sponsors Cling To The Past

Government Backed Stocks?

Group Health Insurance Is Broken, So We’re Fixing It

Everlong is a better way to purchase group health insurance.

Everlong is an exclusive, member-owned medical Captive that enables employers to offer the same level of group health benefits at the lowest cost possible AND improve the health of their employees.

How To Make Money While Sleeping

Send in a referral and lock yourself in as Agent of Record. Earn big bucks while sleeping, playing golf, or cruising towards Tahiti for a week of fun and umbrella drinks…………..A day in the life of an insurance agent has never been better…………..

“Selling ain’t hard when you know how!” – Victor Antonio

Pele & Mike The Insurance Guy

By Bill Rusteberg

Upon learning of Pele’s passing today I found myself reminiscing about a chance encounter I had with Pele’s life insurance broker several years ago.

95% Of All Medical Providers Agree To Less Pay

“Blue Cross PPO plans have a 5-9% lower total cost of care over the competitor’s average. Nationally, Blue Cross PPO members have access to 95% of doctors and 96% of hospitals.”

Lubbock Physician Offers Best Healthcare At The Lowest Price

The Best Healthcare at the Lowest Price – Ready To Begin Your Healing Journey?

WE BELIEVE IN RELATIONSHIPS AND WANT TO TALK WITH YOU TODAY!

Together We Can Create A Customized Plan For You For The Best Healthcare at The Lowest price. Leave your phone number and we’ll have one of our skilled team members call you as soon as possible.

Ben Edwards, M.D. – FOUNDER AND MEDICAL DIRECTOR – Meet Dr. Ben

Blue Cross Fails To Control Health Care Costs Under Federal Employee Health Plan

Blue Cross announces a 2023 rate increase for millions of federal workers proving once again managed care’s failure to control health care costs.

When it comes to controlling costs size doesn’t matter.

Meanwhile in hamlets across the fruited plain, small to medium size employers, led by health care revolutionaries, with a flaming torch in one hand and the Health Rosetta in the other, are proving health care can be fixed by lowering costs and increasing benefits at the same time.

Direct Med Clinic – San Antonio

The Power of Pooling

AGRiP energizes the power of pooling, making member organizations more effective, collaborative and informed (Home – Association of Governmental Risk Pools (agrip.org)

Silver Loading – Squeezing Uncle Sam For More Free Money

The Power of Math Turbocharges ACA Subsidies

Insurance company mathematicians have calculated a method to squeeze millions more in federal subsidies. It’s called Silver Loading………………

Aldeen’s Sunday Morning Bathroom Read

Sunday Morning Bathroom Read ( Paul Harvey “The Rest of the Story” edition):

Saving Phony Money Costs Real Money – The % Of Savings Scam

The boys in the backroom nominate UnitedHealth for the Victor Lustig award!

Salud!

“They’re living healthier lives. We’re saving money, we’re able to share those cost savings back with the employees by keeping their premiums and their deductibles low,” says Brown. “It just becomes this flywheel where everybody wins.”

Blue Cross Says You Can’t Always Get What You Want!

The hospital bill was $674,856: Why did the state pay Blue Cross over $2 million?

By John Tozzi
December 14, 2022 at 12:54 PM

New Jersey, which has one of the country’s largest state employee health plans, has an ongoing conflict with Horizon Blue Cross Blue Shield, alleging the insurer failed to deliver on a program designed to reduce health care costs.

ACA RE – The Best Stop Loss Policy Ever?

By Bill Rusteberg

Transferring risk has never been easier. Lasers are no longer relevant and (almost) never a factor. Rate setting becomes a simple process.

Do You Believe Me Now?

Poor Pearl Roberts! No one believed her…………………

Experience Rating – The Past Dictates The Future

“In our industry we rely on the past to have a glimpse of the future………..”

Aldeen’s Sunday Morning Bathroom Read

Doug Aldeen – ERISA Healthcare Attorney and General Counsel

Why capitalism needs sick people begs the question:
A): There is no money in being healthy unless it is your own cash;
B): The health care sector of the economy is too big to fail;

MedSave Management LLC

MEDSAVE MANAGEMENT LLC is pleased to announce a new health care plan option members may choose when seeking medical care.

CA Insurance Services, LLC

CA Insurance Services, LLC focuses on providing health benefit producers with innovative funding options not available through the traditional fully insured programs offered by national and regional insurance carriers.

Butler Finds Low Hanging Fruit

Josh Butler discusses strategies to tackle high cost drugs – excellent presentation

San Benito ISD Awards Agent of Record

San Benito Independent School District awards Agent of Record for the district’s employee benefits program.

TRS ActiveCare Plays Up The SB1444 Poison Pill Provision

QUESTION FOR THE BROKER: How can we secure a firm stop-loss rate for the next plan year? (ASO only)………Can we lock in our liability for the next plan year?

ANSWER: You can’t.

The Rise of Reference Based Pricing & The Future of Health Care

“A Community Health Plan is currently under development in central Texas. It will incorporate ER, Lab & Radiology, and direct primary care at a capitated rate of less than $125. A cash based reimbursement wrap for all other covered services through a cash pay provider network will cover remaining covered medical services.”

Continue reading The Rise of Reference Based Pricing & The Future of Health Care

Parametric Insurance

Unlike traditional insurance, which relies on lengthy loss adjustment procedures, parametric insurance pays out when a predefined event occurs as measured by a specified parameter or index.

Upstart Drug Pusher Challenges Drug Cartel

Battle of The Drug Pushers Pits David Against Goliath

Mark Cuban’s Cost Plus Drugs Expands To Employers In Quest To Disrupt Big Pharma

Brian Bushard – Forbes Staff

Dec 10, 2022

Billionaire investor Mark Cuban’s self-titled low-cost pharmaceutical company Mark Cuban Cost Plus Drug Company partnered with a major pharmaceutical company this week as the Dallas Mavericks owner looks to access employer benefit programs and compete more directly with pharmacy giants like CVS, Rite Aid and Walgreens.

Aldeen’s Sunday Morning Bathroom Read

Doug Aldeen• Healthcare Attorney and General Counsel

Sunday Morning Bathroom Read (Final Jeopardy Edition): This movie line best summarizes a plan sponsor’s response to the Aetna PBM RFP:

Risk Management: “Having The Right Culture Is Key”

Does best in class risk management pivot on personalities?

Before you waste too much time with a prospect, its best to determine up front if they are a fit for your strategies to control and lower risks. Compatibility and shared philosophies should be determined during your first interview (Yes, you are interviewing the prospect but they don’t know it). That meeting will either be your last or it could be the start of something amazing.

Compassionate Care Plan

Imagine an employer sponsored, tax supported health plan that’s free, covers virtually every needed health care expense, that’s designed specifically for those in immediate dire need of better health care when it’s needed the most, who otherwise would face looming, imminent catastrophic out-of-pocket medical expenses.

World’s Top-Selling Drug Going Off Patent Means Big Bucks for Middlemen

AbbVie’s Humira has raked in about $200 billion over its lifetime.PHOTO: JOE BUGLEWICZ FOR THE WALL STREET JOURNAL

As AbbVie’s Humira faces copycat biologics, the biggest beneficiaries will be the middlemen negotiating and dispensing the drugs such as Cigna and CVS.

Bupa Arabia

Rx Manufacturer’s Assistance Programs

Attorneys Brady Bizarro and Andrew Silverio discuss manufacturer/copay assistance programs and outline some of the different approaches being utilized to manage specialty drug spending. Also on the agenda is a current lawsuit against one such program administrator, and how the landscape might be shaped in the coming months.

Government To Gift Millions More To TRS ActiveCare?

The amount of $286,337,761 is allocated for the purpose that premiums for TRS and TRS ActiveCare insurance policies not increase as a result of coronavirus-related claims……

Bill Introduced Criminalizing Private Health Insurance

Health Insurance Brokers Face Life Sentence

It shall be unlawful for:

(1) a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act; or

(2) an employer to provide benefits for an employee, former employee, or the dependents of an employee or former employee that duplicate the benefits provided under this Act.

Half Pregnant Tulip Lovers vs Cliff Dwellers

Progressive plan sponsors are either half pregnant flower lovers with a passion for tulips or cliff dwellers not afraid of sharks.

Rx Patient Assistance Programs – A Growing Risk Transfer Strategy

Employers, Insurers Use Patient Assistance Programs To Offset Their Own Costs

Rx patient assistance programs become a de facto stop loss policy (and lucrative boon for third party intermediaries facilitating the process). Add in IRC 501r for good measure and a plan can cut costs back to 1980’s levels. Then add in DPC, controlled referrals, and cash pay and you’ve freed up so much money you can buy each employee a Cadillac for Xmas plus a week’s vacation in Tahiti. Life is good.

Most Brokers & Plan Sponsors Are Paralyzed By Fear

We were reminded today most brokers and plan sponsors are paralyzed by the fear of venturing into the world of Reference Based Pricing.

Launch of ‘Business for Medicare for All’

“We are business owners who believe our health insurance costs should not increase every year by double digits. Our payments to profiteering health insurers have swelled as our employees have been offered worse health care coverage. At our companies, rising costs paired with declining performance is unacceptable. So why should we accept this exploitation of our companies from health insurers?”

Santa Brings Joy To Millions of Americans

A majority of Americans see their wishes come true from open borders, recession, Green New Deal to almost free health insurance, the best gift of all, made possible by giving insurers a direct line to the federal treasury to the tune $30 billion in 2022.

Plan Sponsor: “Give It To Me!” Anthem: “Screw You”

“We operate under the belief that vendors don’t want us to know their business because it won’t be good for them, so we remove that barrier as best we can.”

This Small-Town Pharmacy May Be Model For More Affordable Drugs

Honest Rx operates like any other pharmacy in the United States — with one big exception. It does not accept health insurance.

Doctors Revolt Against Hospital System

Eric Bricker, MD

The Story of Tryon Medical Partners shows us that if doctors don’t like the way a hospital is running their practice, they can leave and be successful.

Medical Trend Driven By Greed

“Slaying Healthcare Dragoons Is Our Business” – RiskManagers.us

“Another way hospital systems exploit their growing monopoly power to maximize their profits is a shady practice known as “dishonest billing.” This occurs when big hospital systems buy up small, independent doctor’s offices and take over their billing operations, tacking on additional hospital facility fees, despite the patient never stepping foot inside a hospital and receiving the same service from the same physician.”

Merry Christmas and Happy Holidays! I sincerely wish everyone an enjoyable holiday season. All the best to you and yours – Doug Aldeen

Discount Dental Plan Provides Extra Perks

Taxpayers Gift Hospital $538,000,000 In Return For $49,000,000

Pssst Godfather! We’ve Been Double Crossed! Should I Send For Luca Brasi?

I’m gonna make you an offer you can’t refuse. I’ll lend you $538 interest free if you give it back. Capisce? ………. Ok, sure, here’s $49 back, now we’re even.

“Pssst Godfather! Even worse, the $49 is counterfeit manufactured by a chargemaster printing press!”

Here’s Your Menu, May I Get Your Drink Orders First?

“Knee replacement? That’s $18,000, tip included. You will find it under “House Specialties” here” said the waitress. “OK Great! I’ll take two of those” says the customer. “And hook me up with a slow drip Miller Lite.”

“I’ll take the bursectomy” says his wife as she elbows her husband with a playful grin. “Does it come with an after dinner sling or is that extra? And I’ll take an Epidural Martini, shaken not stirred.“

HB 3752 Authorizes Texas Mutual To Offer Alternative Health Insurance

November 30, 2022

The Texas Mutual board of directors approved the initial steps for creating a health coverage-focused subsidiary. Last year the Texas Legislature authorized Texas Mutual to potentially offer health coverage solutions through a subsidiary that could help the people of Texas and Texas businesses.

AWP Can Be 125 X The Drug Cost

“An 80% Discount Off of AWP is Still 24X the Cost of the Medication……”

136% Of Respondents Report Either a Negative or Positive Patient Experience

“Surprisingly, when asked about healthcare experiences, 76% said they have had a positive patient experience in the past three months and 60% said they have had a negative experience.”

The Broker’s Antidote to Lost Revenue

New Employee Benefit

No administration
No payroll deductions
No reconciliation

Get an Underwritten quote without PHQ’s in 48 hours!!!

This is where the small group health insurance market is going – rapid simplified underwriting. In the not too distant future we believe brokers will have the ability to field rate firm quotes in minutes.

Lionel To Partner With Lisa?

The Lisa Plan, an employer funded cash driven health plan strategy, is considering a partnership with Lionel to provide timid brokers and plan sponsors with sleep insurance designed to allay fears of the unknown. No longer will Lisa Plan members wonder and worry if their plan will be accepted by medical caregivers.

“The Dallas ISD Insurance Scandal” Starring The Cookie Jar Bandit

This is old news but relevant in today’s age of cell phones and instant messaging………

“Carver Dan Peavy (Peavy) was elected a trustee for the Dallas Independent School District (DISD) in 1986, so serving until 1995. By the early 1990s, he controlled purchases of insurance for DISD employees. He was a friend and business associate of Eugene Oliver, an insurance agent who had been convicted as an accomplice to murder” (PEAVY v. WFAA TV INC ).

When You Have A Good Product, People Will Buy It When It’s Free

“The Biden administration announced Tuesday that it’s seeing a big uptick in the number of new customers buying private health insurance for 2023 from the Affordable Care Act’s marketplace. The boost in enrollment is largely driven by generous subsidies—extended through 2025 in the Democrats’ $1.9 trillion coronavirus relief law—that keep monthly premiums payments at $0 or just a few dollars monthly for most people who sign up.“

Are You Licensed? ISI Has A Job Opening For You

Operating worldwide, Insurance Supermarket International Inc. operates through a network of offices including Toronto, Canada; Miami, U.S.A.; and Brasov, Romania, with a team of over 700 globally….

The Biggest Company In The World

by Daisy Wolf and Vijay Pande

We think the biggest company in the world will be a consumer health tech company.

Aldeen’s Sunday Morning Bathroom Read (post turkey stupor/WTF edition)

Doug Aldeen• ERISA Healthcare Attorney and General Counsel

“WTF” can best be summarized as follows:

A) William “The Fridge” Perry lining up as a fullback (all 338 lbs) for the 1985 Chicago Bears;

B) A number of not for profit hospitals charging 13% interest on a “credit card” for outstanding medical bills for individuals that are already functionally uninsured and now deeper in debt;

C) Marilyn Monroe/JFK/Lee Harvey Oswald/ all killed within 13 months of each other;

D) A NYC investment bank charging recently released felons $30 transaction fee’s on a $500 debit card (true story);

E) All of the above.

Why Can’t Group Health Insurance Be This Easy?

Easy Access Health Insurance In Minutes………………..

Our new and improved online quoting system is now live! You can now get instant quotes and rates, without ever leaving your desk. So, if you’re looking to find a new health insurance company, or just want to find out what you qualify for, you can do it right now! Get started by clicking below – Isaac Higgins

Time Value of Money In Healthcare

Why would any plan sponsor that’s able to pay cash at the point of service reimburse a hospital more than their discounted cash price?

The time value of money in a typical claim cycle averages 90 days X cost of money. What is 90 days worth in the value of services received in today’s dollars? Suppose a claim under a PPO contract is paid at 225% of Medicare and the cash price is 100% of Medicare, the time value of money under a PPO contract in this instance is 2.25. That beats money market and CD rates these days.

Transferring Risk To Medicare

Plan sponsors have all sorts of risk transfer strategies from which to choose from. Stop loss insurance is an obvious risk transfer strategy. Then there is ACA mandated HFAP risk transfer and specialty drug risk transfer. How about transferring risk to Medicare? It’s the older folks who have more medical expense needs often driving up costs for a group plan.

Rx With A Little Help From Our Friends

TotalRx.net is a valuable way to get access to network contracted rates, without worrying about deductibles or maximum benefit limits. With an unlimited formulary, and zero program rules, members are given a freedom seldom available to them in the benefit marketplace today.

67% Of Americans Believe Health Insurance Is Cheap As Hell

“There are plenty of Americans who are fine with what they are paying for insurance, including 67% who think their insurance premiums are fairly priced or inexpensive……..69% spend less than $500 per month on insurance…………….53% spend less than $250 per month“

And best of all, 60.6% of Americans pay no income taxes…………….life is good in America!