Sunday, May 12, 2024

How Do You Pay Your Reference-Based Repricer?

When engaging in Reference-Based Pricing on your employer health plan, there are several different ways you can pay that repricer: per employee per month, a percentage of billed charges, a percentage of savings, or a flat fee. Which one or ones are best, and why?

Wednesday, May 8, 2024

Fleecing Employers - Health Insurer Overrides

What are health insurer overrides?  What do they mean for employers and employees?  How do you know where they are most likely to lurk?  

I've uncovered a new nugget of insider intel on this one - insurance brokerages are turning the volume up to 11 on their insatiable longing for these hidden payments.


Friday, March 22, 2024

I’m Coming Home

Today, with the greatest sense of professional pride I’ve ever had, I announce that I’ve come home to where I belong and where I will finish my career.  I’ve been in benefits full-time for 22 years (32 years if you add part-time work after high school, during college, and in law school).  Since 2002, I forged unimaginably rewarding and life-changing bonds with clients, teammates, and vendor partners.

Unfortunately, also during that time, the underlying businesses housing my team’s efforts were sold.  Each time, this corporate shuffling resulted in a larger, more bureaucratic, and an entity less aligned with our values.  Liberty Benefit sold to BB&T, which then merged with Sun Trust to form Truist and rebrand and reshape their hundreds of insurance agencies as McGriff. 

Culturally, philosophically, and at the deepest levels of intrinsic motivation, these entities became further and further removed from my mission and purpose:

To provide businesses with the most cost-effective, innovative, and high-quality employee benefit plans while simultaneously helping them manage their risk and compliance and treating every dollar as though it is the last an employee can afford to pay for care.

I wrote that in 2004, and it has been my North Star ever since.  Regrettably, often the larger an organization grows, the further it removes itself from such a mission.  Stock prices, shareholder demands, quarterly growth, EBITA, and a pursuit of new sales at all costs are not conducive to making sure each client continues to receive exactly what it needs – even if they were last year’s sale. 

So, after watching changes that did not align with my business values take over and then seeing private equity swoop in, 2023 became a year of endless introspection, prayer, and discussion with my wife. Something had to change. 

With a heart full of pride, energy, and vigor, I announce today that I am the newest member of the Mahoney Group, a privately held and employee-owned organization with no interest in Wall Street’s stock prices or private equity.  As I restart my career at 50 years old, I am now brimming with joy. 

I used to think I wanted to retire between 50 and 55.  Now, I chuckle at that assessment. The kids are grown and on their own.  My youthful exuberance to hunt, fish, bike, and backpack is still there, but only as a hobby—not an all-consuming addiction.

No. I know where I can make the biggest impact, and that is by providing businesses with the most cost-effective, innovative, and high-quality employee benefit plans while simultaneously helping them manage their risk and compliance and treating every dollar as though it is the last one an employee can afford to pay for care. 

In so doing, my new teammates at the Mahoney Group and I will fight doggedly to ensure you are not being taken advantage of by a deeply flawed healthcare delivery system. 

On we march! 

Craig Gottwals

Wednesday, December 20, 2023

On Armstrong and Getty for a Couple Hours This Morning

7 AM Hour - Just a Wee Bit Less Dynamic: features our guest, Craig, the Obamacare Guru, who joins Jack to discuss...

  • The escalation of Christmas...
  • The Trump/Colorado ruling...
  • Jack's confrontation conundrum...
  • Immigration...
  • Those magical family moments! 

8 AM Hour - Just Eat Your Cotton Candy! features Craig, the Obamacare Expert, who joins Jack to discuss...

  • The Trump/Colorado decision...
  • Weight Loss Drugs...
  • The Ukraine/Russia War.
  • Expert military analyst Mike Lyons joins the show to talk about the Israel/Hamas war.


Friday, September 15, 2023

Healthcare's Final Frontier: Navigating the Wild West of RBP with Industry Renegades

Omar Arif of ClaimDOC & Scott Schnaidt of HST on All Things RBP

Ever imagine healthcare could feel like the Wild West? Welcome to the untamed lands of Reference-Based Pricing (RBP), the sizzling frontier where a select few employers unleash radical savings while giving the traditional PPO system a stiff arm.

Unveil a world where only 3-4% of employers dare to tread, but where jaw-dropping 30-40% savings rain like gold and concierge-level service is the sheriff in town.

Curious about RBP's magic? This isn't just healthcare. It's "Health-FAIR!" Here, employers "price-match" medical costs against benchmark prices, slicing their claims in half compared to big insurers.

Projections say employer healthcare costs will shoot up another 7-9% in 2024. Yet Medicare Part D Premiums are projected to decrease by 1.8%. All major insurers participate in both markets. The lesson? Employers with private insurance are subsidizing Medicare. But hold your horses. With RBP, brace yourself for a 0-2% trend that turns the tables on traditional care.

Jump into this roller-coaster ride of a podcast with your guide through this maze, joined by two titans of the trade—Omar Arif of ClaimDOC & Scott Schnaidt of HST. They've both cracked the code, each in their unique ways, and the results? Nothing short of spellbinding.

🎯 What's on Tap:
  • The gears and levers behind RBP
  • Navigating the legal minefields
  • Secrets from Third-Party Administrators (TPAs)
  • RBP's performance across the geographical board
  • The art of handling balance bill claims
  • Litigation: When & How Often
  • Co-fiduciaries: The real deal or just smoke and mirrors?
  • Show Me the Money: Their pay structure dissected
  • Year-end Report Cards: The Good, the Bad, and the Profitable
And just when you think it couldn’t get any cooler—did one of these guys actually play pro baseball in a global tourney, while the other rocked the stage with NIRVANA? 🎸⚾

Lock in your earbuds. Prepare for a mind-bending journey. You’re entering "The Repricers"—Healthcare’s Final Frontier! 🌌🛸

Saturday, September 2, 2023

The U.S. Will Finally Start Negotiating Drug Prices with Armstrong and Getty

I spent one morning this week chatting with Armstrong and Getty regarding the news that the federal government will finally begin negotiating the price of drugs.  10 of them.  Two and a half years from now.  

Well, it's a start...

Tuesday, August 8, 2023

It's A Government Healthcare Complex: Craig Gottwals Talks To A&G

Your health insurance costs and premiums have skyrocketed compared to the rate of inflation since Obamacare passed. Meanwhile, insurance carrier stock prices have grown by 1900% in the same timeframe.

"They're making unimaginable amounts of money... off of you." -Joe Getty

Craig Gottwals, aka "Craig the Healthcare Guru,” talks about that and more in a new episode of A&G's Extra Large Podcast.

Listen to the Armstrong & Getty Extra Large Podcasts featuring Craig.

Originally posted here

Saturday, July 15, 2023

Required Leave for Any Reason, Ozempic, and Coverage for Gender Affirming Care

Tools & Webinars:

Compliance News:

Pharmacies are Sharing Sensitive Health Data with Facebook - "Looking for an at-home HIV or Plan B test on CVS’ website is not as private an experience as one might think, and CVS is not the only pharmacy sharing this kind of sensitive health data, according to a KFF Health News investigation. We found trackers collecting browsing- and purchase-related data on websites of 12 of the U.S.’ biggest drugstores, including grocery store chains with pharmacies, and sharing the sensitive information with companies like Meta (formerly Facebook); Google, through its advertising and analytics products; and Microsoft, through its search engine, Bing."

The IRS recently issued Notice 2023-37 to update its guidance for high deductible health plans (HDHPs) on expenses related to COVID-19 testing and treatment. The notice also clarifies whether certain items and services are treated as preventive care under the tax rules for HDHPs, and confirms that for plan years ending after Dec. 31, 2024, an HDHP is not permitted to provide benefits for COVID-19 testing and treatment without a deductible. 

Open Issue: Employer-Sponsored Health Plans and Coverage of Gender-Affirming Care

June 28, 2023 – Jackson Lewis P.C.

Whether an employer-sponsored health plan must cover gender-affirming care is often dependent on whether the employer’s health plan is fully-insured or self-insured; fully-insured plans must provide gender-affirming care to the extent required by applicable state and federal law, while the law on categorical exclusions for gender-affirming care in self-insured plans continues to develop. 

Talk about an FMLA leave headache! This one was a migraine

June 27, 2023 – HR Morning

A federal appeals court rejected claims filed by terminated employees who sought FMLA leave along with many others, ruling that the employer had good reason to believe the employees acted dishonestly and sought leave for an improper purpose. Employers can also take away from this article a few tips to curb FMLA leave abuse.  

July Is the New January: The Pace of New State Laws Heats Up

June 26, 2023 – Littler Mendelson P.C.

This article offers insight into an array of labor and employment laws and ordinances from across the country, state by state, that take effect mid-year and will implicate employers’ compliance obligations. 

New Trend in State Laws, Paid Leave for Any Reason - "In May 2019, Maine became the first state in the nation to require private employers to provide paid leave for any reason when Gov. Janet Mills (D) signed LD 369. Nevada followed a month later, in June 2019, when then-Gov. Steve Sisolak (D) signed SB 312, which also granted paid leave for any reason. Illinois is poised to join their ranks on January 1, 2024. In March 2023, Gov. J.B. Pritzker (D) signed SB 208, which says that beginning on January 1, 2024, private employers must offer their workers five days paid time off for any reason after they’ve completed a 90-day probation period."

  • In Nevada, for example, Employers may limit the use of paid leave to 40 total hours per benefit year and may prevent an employee from using any accrued paid leave until the employee reaches their 90th day of employment. Employers may also set minimum increments of paid leave which an employee may elect to use, so long as that limit does not exceed 4 hours.

Benefits News:

A Couple Retiring in 2023 Needs $315,000 in Retirement Savings Just to Cover Medical Expenses in Addition to Medicare - "The after-tax cost for medical expenses throughout retirement for a single, 65-year-old retiree held steady at $157,500 ($315,000 for the average retired couple at the same age), according to the new 2023 Retiree Health Care Cost Estimate, which tracks retiree healthcare expenses annually."

Renewals Not Looking Good for UHC Clients: "UnitedHealth Group extended its streak as the most profitable company among major national insurers in the first quarter of 2023, reporting $5.6 billion in earnings. By comparison, fellow healthcare giant CVS Health reported the second-highest profit in the quarter at $2.1 billion, less than half of UnitedHealth's haul. CVS' profit also declined year over year, as it posted nearly $2.4 billion in the first quarter of 2022. UnitedHealth also takes the top spot on revenue for the quarter, reporting $91.3 billion. That's up from $80.1 billion in the prior-year quarter. CVS again lands at No. 2 on revenue, posting $85.3 billion."

Will the Doctor See You Now? The Health System's Changing Landscape - "About 48% of primary care physicians currently work in practices they do not own. Two-thirds of those doctors don’t work for other physicians but are employed by private equity investors or other corporate entities, according to data in the “Primary Care Chartbook,” which is collected and published by the Graham Center.... it now takes an average of 21 days just to get in to see a doctor of family medicine, defined as a subgroup of primary care, which includes general internists and pediatricians. Those physicians are many patients’ first stop for health care."

Health and Wellness:

Watch The Truth About Weight Loss Drug Ozempic with Dr. Peter Attia - a one-minute short.

Trusting The Science: The following is a list of the 20 largest settlements reached between the United States Department of Justice and pharmaceutical companies from 1991 to 2012 - Pfizer claims the largest criminal fine in U.S. history, while GlaxoSmithKline holds the largest pharma-fine in history when combining civil and criminal penalties.

What you need to know about Ozempic & Mounjaro - "But I want all my patients and the public to know that the appetite and weight loss effects do not last forever. Effects on hunger, cravings control, sweet cravings, mood & fullness are TEMPORARY and return to baseline between years 1 & 2. This was shown in surveys taken from patients using the medication over the long term."

Just 3% of adults show no major health risk factors linked to death - "Overall, most of us have something wrong with us, and we’re more likely to have a lifestyle health-risk factor now than in the ’80s and that’s actually associated with even greater mortality risk now than before."

Ozempic, Weight-Loss Drugs Probed Over Reports of Suicidal Thoughts - "Novo Nordisk A/S’s weight-loss medications are under investigation by the European Union’s drugs regulator after a small number of reports of suicidal risks were referred to the watchdog. The European Medicines Agency is looking at adverse events noted by the Icelandic Medicines Agency, including two cases of suicidal thoughts linked to the drugs Saxenda and Ozempic, the EMA said in a statement Monday."