Risk Managers

A Virginia nurse practitioner has filed a lawsuit against the CVS drugstore chain after she claims the company fired her for refusing to provide abortion-inducing drugs, a service that violated her religious beliefs.

No participation requirements, immediate firm quotes, RBP with PPO wrap, no employee applications required (coming soon), direct contact with underwriters…………………

Health insurance commissioned brokers do everything possible to control their turf while sitting on the other side of the table.

WLG (Wagner law Group) / Sep 21, 2022  / / Read Article

A Texas federal district court, in Braidwood Management, Inc. v. Becerra, has held that the Affordable Care Act’s (“ACA’s”) requirement that most group health plans and health insurers cover certain recommended preventive services without cost-sharing violates the Appointments Clause of the U.S. Constitution.

EZaccessMD is the only healthcare provider that is revolutionizing the healthcare industry by combining traditional telemedicine with mobile urgent care.

Lower-than-expected spending on an expensive drug and other things means beneficiaries will pay less next year.

Several years ago, a team of industry veterans founded Araya. We founded our company based on the idea that all discounts and pharmacy rebates should be passed on to the client – a full pass-through model. Today, our team of licensed pharmacists with decades of PBM experience remain committed to this model.

This graph represents all you need to know about what’s driving healthcare costs in this country.

Interesting results of a claim study on the Edinburg Independent School District’s self-funded health plan several years ago show the Medicare equivalent reimbursement rates compared to the district’s PPO allowed amount.

“This is part of an overall national trend to move away from PPO plans that come with high costs to consumers and offer little in the way of coordinated care”

                                – Blue Cross & Blue Shield of Illinois

“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.” 

By Reed Abelson and Margot Sanger-Katz

Oct. 8, 2022

The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.

A new Direct Primary Care employee benefit program for Houston employers. Convenient clinic locations throughout the Houston metroplex…………………..

In a recent blog posting titled Battle of The Blues we discussed the peculiar effects of Texas Senate Bill 1444, legislation which effectively eviscerates the TRS ActiveCare government health plan.

RiskManagers.us Service Schedule is flexible, allowing plan sponsors to pick and choose the level of service required.

By Bill Rusteberg

Texas recently gifted TRS ActiveCare $721,000,000 in additional funding ostensibly to cover claim losses for this +400,000 member government health plan in order to reman competitive. This cash infusion comes just at the right time as TRS ActiveCare is fighting to stay relevant since passage of Senate Bill 1444.

Blue Cross of Texas is betting on Red & Black – they can’t lose. But wait! A Fifth Column arises funded by Blue Cross of Alabama…………

By Craig Lack

Everything in healthcare is undergoing change. Companies must also change — they must change the strategy, tactics and people involved in their decision-making process.

By 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.

By Jawad Arshad / ebn / October 03, 2022 / / Read Article

A direct-pay network can be set up to cover 85% to 90% of all medical events, which involve everyday acute primary care for both in-person and virtual visits, as well as diagnostics like labs and imaging, and pharmacies.

By Sahil Kapur / NBC News / Oct. 2, 2022 / / Read Article

Republicans are abandoning their long crusade to repeal the Affordable Care Act, making the 2022 election the first in more than a decade that won’t be fought over whether to protect or undo President Barack Obama’s signature achievement.

OCTOBER 1, 2022 • ERIC L. REINER

When a Philadelphia law firm was facing a 12% increase in the cost of the health insurance it provided for its 55 employees and their dependents, it needed to explore other options.

The insurance industry is still largely reliant on manual processes, particularly when it comes to lines of business that use agents and brokers for distribution.  

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?

Reference Based Pricing plans are increasingly becoming targets of hospitals seeking “found money” in desperate attempts at solvency instead of efficiency. RBP plan sponsors can expect a slew of demand letters for claims going back three to five years of “uncompensated care” to the tune of millions of dollars.

This elementary course in underwriting offers an easy way to estimate your renewal with enough certainty that you can set your accrual rates and proceed with open enrollment. Underwriting is not rocket science. But it takes experience.

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.”

We recently reviewed a renewal offer by Blue Cross on a fully insured account. The loss ratio shown was 98%. The renewal action required a 16% rate increase. That just doesn’t add up.

Texas school district seeking stop loss proposals faces significant additional risk exposure through specialty drug lasers.

“The announcement of expanded fertility offerings comes after Walmart in August announced it was expanding its abortion coverage following the Supreme Court ruling that scrapped a nationwide right to abortion.”

Dr. Bricker, in the video above. explains what Direct Primary Care (DPC) is but he doesn’t discuss the three different methods DPC can be incorporated into a group health plan.

Frontier Direct Care taps Flume Health to launch new health plan

“We’re basically able to go to an employer group now and say, ‘Hey, we have this package that will fit your entire healthcare needs,” Lazzopina said. “You’ve got your primary care with Frontier and then we’ve got all of the catastrophic coverage built around that for employer groups.”

Physicians in Pyongyang’s People’s Hospital No. 2 wearing masks. (Rodong Sinmun)

N. Korea begins annual inspection of hospitals in the provinces

“Hospitals have launched campaigns to at least tidy up the sanitary state of the interiors and exteriors of their buildings in response to the announced inspections,” a source told Daily NK

A Common Sense Approach to Health Care. All financial barriers to health care are eliminated. Providers are paid in cash at the point of service. Never a balance bill.

Five powerful questions that will help you decide if the prospect is a fit for your services:

More employers are using the Nancy Reagan risk management method to eliminate high cost drugs through their PBM drug dealer partner. Employers simply can’t continue to pay for expensive specialty drugs anymore.

Many years ago I worked for a large insurance company which had a fair amount of federal contracts. One day an executive sales position became open. “Know any Hispanics for the position Bill?” asked the boss. “What! Why does the applicant need to be Hispanic?” I asked. “Because the Home Office says so, that’s why! said the boss.

Mr. Gybbon worked in London as a Salter of meat and fish used to preserve meat. His insurance claim ended up being the first in history to be disputed by the time honored “Loophole Card.”

The Reinsurance Treaty was a diplomatic agreement between the German Empire and the Russian Empire that was in effect from 1887 to 1890. Only a handful of top officials in Berlin and St. Petersburg knew of its existence since it was top secret. (Reinsurance Treaty – Wikipedia)

We are rewiring healthcare for self-funded employers and healthcare providers. Join us in cutting out the middle-man.

Attorneys find opportunities in representing plan members who sue plan sponsors over breach of fiduciary duties. Every plan sponsor should watch this video.

A Risk Management Tool Few Are Aware Of……………………….

HEALTHCARE COSTS FOR EMPLOYER-SPONSORED PLANS ON THE RISE

You can’t experience rate something that has never happened before. You can only experience rate after the fact. Was the “going in” equal to the “going out”?

Underwriting is not all about numbers. Intuition plays a role. A combination of both makes for winners in Las Vegas.

Price increases are not yet reflected in trend factors payers use to set premiums…….claims shot up in 2021 due to residual demand from COVID-19………claim activity is projected to normalize in 2022……. health plans will be under pressure to increase provider reimbursement rates in reaction to the rise in inflation as their provider contracts come up for renewal…………..

Ask anyone what “COVID” stands for and you’ll probably get blank stares. So we thought it would be good to explain it.

Louisiana regulator proposes $20 million plan to fund insurer incentive program

BSA Health System (BSA) in Amarillo sent Blue Cross a notice of termination and a demand for higher prices. If neither side can agree, BSA intends to leave the Blue Cross network on Dec. 8, 2022

Less than 60% of all American companies offer health benefits to their employees.

About 57% of the companies offer health benefits to their employees which is less than the 68% and 69% recorded in 2000 and 2010. Approximately 99% of all large firms and 56% of all small firms provide health coverage to employees. The lowest share of businesses with health benefits of 47% is seen among companies with 3-9 workers, according to health insurance data.

What’s the “real” employee rate for TRS ActiveCare? Will TRS ActiveCare compete in the voluntary benefits market next year? Will the government health plan morph into a high risk pool by acting as a stop loss carrier?

With its employee health plan in financial crisis, Montana hired a former insurance insider who pushed back against industry players with vested interests in keeping (health care) costs high. Now we learn a major industry player is back in the saddle.

By Wendell Potter – President at Center for Health and Democracy

On top of what you and/or your employer already pay insurance companies in annual premiums and out-of-pocket expenses — insurers also get a skim of your taxes!

Costco has a health insurance plan and marketplace where clients can view and compare prices for different health insurance lines. To do this, Costco recently merged with Custom Benefits Consultants (CBC). How are local independent insurance brokers going to compete with Costco?

I’ve traveled the state promoting direct primary care but little did I know the DPC revolution has gained a foothold just miles from our ranch in little sleepy Cuero Texas – Bill Rusteberg

The acquisition is projected to place over $34 billion in premiums annually, and employ more than 5,100 teammates across North America.

According to the Social Security Administration, 1 in 4 of today’s 20-year-olds will become disabled during their career.

Here’s proof health care costs have remained essentially static for the past 10 years and more. This is a case study on a risk pool established in 1998 for several school districts in South Texas. They have not had a rate increase in 15 years and have improved benefits at the same time. The pool is well reserved. Employee only rate is in the low $300’s.

Employers, did you know each of your valued employees may be worth $26,000 more than what you’re paying them these days? The government thinks so. Apply today and get their money. (P.S. – you don’t have to give it to your employees!)

An extra $26,000 per employee could sure sooth the sting of high cost group health insurance…….

Selling health insurance is not a created sale, it’s a replacement sale………………..

This case bears watching closely. If arrangements like Data Marketing are legitimate single employer ERISA-covered health plans, other similar arrangements could proliferate.

This airs tonight at 10 pm. The John Oliver video started it all…

HospitalRe – Turning Tax Exempt Hospitals Into Insurers

Most self-funded health plans have traditional stop loss insurance to protect against unexpected and catastrophic claims. But many are not aware there is another risk transfer strategy – HospitalRe.

SOURCE: ALS Crowd

Before starting treatment, patients and their caregivers should meet with the financial counselor at the facility where they will be treated. Each hospital will have its own financial counselor within each specific clinic. The counselor will help determined coverage and estimate out of pocket costs. There may be restrictions on treatment options covered by Medicare and Medicaid. After you have met with the counselor, the resources below can help bridge financial gaps.

Controversial Health Plan For City Employees Rejected

By Gerry May – Sep 9, 2022

Mayor Adrian Perkins, flanked by other city leaders, prepares to clarify developments on the health care plan. 

SHREVEPORT, La. — City leaders backtrack on health care. For two days, we were led to believe that a controversial three-tier insurance plan for city employees and retirees had been approved.

But it turns out that it was rejected.

11th September 2022 – Author: Matt Sheehan

Kathleen Reardon, Chief Executive Officer (CEO) at Hiscox Re & ILS, has said that she sees “interesting opportunities” for her company at the upcoming January 1^st renewals, as signs point to continued reinsurance price increases.

We partner with select benefit consultants, PBMs, and TPAs in an effort to provide the most competitive pricing for expensive specialty and name brand medications.

At the time of its 2021 funding, Cityblock , a $5.7 billion startup company, cited a 15% reduction in emergency room visits and a 20% reduction in in-patient hospital stays among its first generation of members.

Nova’s New Podcast Episode Discusses Benefits of Direct Primary Care, Relationship with PCP

MyHealthGuide Source: Nova, 9/8/2022

BUFFALO, NY – Have you ever wondered why your out-of-pocket costs for a visit to the emergency room are much greater than for an appointment with a primary care physician (PCP)? Have you noticed a difference in the quality of care and attention you receive?

“When I asked what the total billed charge for the procedure was going to be, that completely flummoxed them………………….“

Most states use age 21 as a base rate and then apply a multiplier based on the individual’s age. Rates are generally cheaper for individuals 20 years and younger and higher for ages 22 and up. The premium multiplier is capped at 3.00 for older people — older individuals will not pay more than three times the rate paid by a 21-year-old based on age alone.

Employees expect employers to provide health insurance and pay for it. Employers do the former but never the later…………………….