DAILY UPDATE: CVS Exits ACA Marketplace as Markets Flounder

Posted on May 6, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Aetna is waving goodbye to the ACA marketplace. Executives announced during CVS Health’s Q1 2025 earnings call on May 1 that the insurance giant is withdrawing from the individual marketplace created under the Affordable Care Act, as the company expects to lose as much as $400 million from that part of the business in 2025.

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Stocks sank a bit today while investors remain in wait-and-see mode. All eyes are on Jerome Powell & Co. this Wednesday: The market thinks the Fed will stay put until June, while some pros think the next rate cut will be in July.

Among the major indexes, the Dow Jones industrials fared best, though it was only up 0.1%. McDonald’s and UnitedHealth led blue chips with gains of more than 1%. Apple lagged most, dropping 2.6%. Chevron skidded more than 2%. The NASDAQ composite fell 0.4%. Trade Desk outperformed here, rallying more than 3%, while Charter Communications and Fortinet each rose nearly 3%. Meanwhile, On Semiconductor and Grail lagged, diving more than 8% and 4%, respectively. The S&P 500 dropped 0.4%. The benchmark index’s sectors were mixed, but with a slight downside bias. Energy and consumer discretionary were getting hit the hardest. Industrials and consumer staples made the best gains.

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🟢 What’s up

  • Skechers exploded 24.35% after the footwear retailer inked a deal with 3G Capital to go private.
  • Electronic Arts climbed 2.41% on the news that it has teamed up with Major League Soccer to offer four matches via its mobile gaming platform this year.
  • United Airlines rose 1.07% despite its announcement that it’s cutting some flights out of Newark, New Jersey, where apparently flying is terrible.
  • Howard Hughes Holdings gained 2.81% thanks to a $900 million investment in the real estate company from Bill Ackman’s Pershing Square.

What’s down

  • Sunoco sank 5.64% on the oil & gas company’s plans to acquire Canadian gas station chain Parkland Corporation for $9.1 billion.
  • Shell fell 2.28% on reports that the company is considering ways to acquire rival BP.
  • ON Semiconductor lost 8.35% despite outpacing analysts’ estimates on both the top and bottom lines, as shareholders focused on warnings of weaker demand.
  • Tyson Foods fell 7.75% after the meat giant missed sales estimates and warned revenue will remain flat in the coming year.
  • Loews may have beaten analysts’ estimates on revenue, but the luxury hospitality stock still fell 1.77% after missing on profits.
  • Wolfspeed, which is a company name we will never get tired of writing, gave up another 8.52% following a wild short squeeze last week.

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DAILY UPDATE: CVS Splits as Stocks Down in Slow Session

Posted on November 5, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Among consideration for CVS is splitting up its assets: CVS Pharmacy, pharmacy benefit manager CVS Caremark, and insurance arm Aetna. The company has reportedly been in talks with bankers about the move, Reuters reported early this month.

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STOCKS UP

  • Just as Nvidia will replace Intel, Sherwin Williams will replace Dow Inc. on the Dow (how embarrassing, getting kicked off an index you share a name with). Sherwin Williams popped 4.59%, while Dow Inc. fell 2.08%.
  • Chewy is also getting added to an index, replacing Stericycle on the MidCap 400. Shares rose 6.34%.
  • Peloton pedaled 3.59% higher on a double upgrade from Bank of America analysts, who like the bike company’s higher profit outlook and hiring of new CEO Peter Stern from Ford.
  • Yum! China, the company that operates Pizza Hut and KFC restaurants in China, climbed 7.12% after announcing that new store openings translated into better-than-expected revenue and earnings last quarter.

STOCKS DOWN

Nuclear energy stocks took a big hit today after the Federal Energy Regulatory Commission ruled that Talen Energy could not increase the amount of energy its nuclear plant in Susquehanna, PA, produces in order to power an Amazon data center. Talen fell 2.23%, Vistra Corp sank 3.18%, and Constellation Energy plummeted 12.46%.

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Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) dipped 16.11 points (–0.28%) to 5,712.69; the $DJI dropped 257.59 points (–0.61%) to 41,794.60; and the $COMP lost 59.93 points (–0.33%) to 18,179.98.
  • The 10-year Treasury note yield (TNX) fell five basis points to 4.31%.
  • The CBOE Volatility Index® (VIX)edged up to 22.11, still below last week’s peaks.

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: CVS Health and AI Healthcare Chatbots as Stocks Reach New Highs

Posted on October 19, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

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CVS Health may be breaking up…with itself. The board of directors at CVS Health—the parent company of CVS Pharmacy, pharmacy benefit manager CVS Caremark, and insurance unit Aetna—are working with a group of bankers to review the company’s strategy, which according to Reuters, may lead to a split between its pharmacy division and Aetna.

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Stocks Up

  • Apple climbed 1.23% on a Bloomberg report that iPhone 16 demand has been shockingly strong in China.
  • Verizon Communications will purchase $1 billion worth of US Cellular’s wireless spectrum licenses. Verizon rose just 0.34%—but it’s a huge deal for US Cellular, which popped 7.22%, and Telephone and Data Systems, which owns 82% of US Cellular, and soared 15.40%.
  • Intuitive Surgical rose to a new all-time high, climbing 10.01% on strong earnings powered by sales of its da Vinci device.
  • Lamb Weston, the company behind the french fries you overindulge in every time you go out to dinner, is being pushed by activist investor Jana Partners toward exploring a sale. Shareholders rejoiced, and the stock rose 10.17%.

Stocks Down

CVS Health sank 5.23% on the news that CEO Karen Lynch will be replaced by David Joyner after three years at the helm of the struggling pharmacy/retailer. Joyner ran the company’s pharmacy service business for the last two years.

  • WD-40 seems like the staple of all consumer staples, but the company missed on both revenue and earnings estimates last quarter. Shares fell 4.79% on the news.
  • American Express dropped 3.15% after the credit card company reported a rare miss today, beating bottom-line estimates but missing revenue forecasts last quarter.
  • MGP Ingredients makes all the booze you drink under different brand names, but people aren’t drinking enough. The beverage maker issued preliminary earnings that included a 24% drop in sales. Shares tanked 24.16%.

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Here’s where the major stock market benchmarks ended:

  • The S&P 500® index (SPX)rose 23.20 points (0.40%) to 5,864.67, a new record high close, to end the week up 0.85%; the Dow Jones Industrial Average® ($DJI) added 36.86 points (0.09%) to 43,275.91, also another record high finish, to end the week up 0.96%; and the $COMP gained 115.94 points (0.63%) to 18,489.55 to end the week up 0.80%.
  • The 10-year Treasury note yield (TNX) fell two basis points to 4.07%.
  • The CBOE Volatility Index® (VIX) fell to 18.17, the lowest since September 30.

CITE: https://tinyurl.com/tj8smmes

A new survey results may prompt health systems to second-guess some of their future plans. A recent University of Michigan survey found 74% of adults ages 50+ have “very little or no trust” in health info generated by AI. Maybe it’s not time to roll out chatbots on patient portals just yet.

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DAILY UPDATE: Aetna Ratings Down as Stock Markets Flatten

Posted on August 13, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Aetna, CVS’s health insurance arm and the third largest payer in the US, is struggling amid higher medical costs and lower Medicare Advantage star ratings. After CVS reported a nearly 40% YoY drop in operating income in its Q2 2024 earnings released on August 7th, President and CEO Karen Lynch announced the company will replace Aetna’s president, Brian Kane, and initiate a $2 billion cost-savings plan.

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What’s up

  • Nvidia jumped 4.08% after it was named a top “rebound” stock by Bank of America.
  • Keycorp leaped 9.24% on the news that the Bank of Nova Scotia will invest $2.8 billion in the company.
  • Robinhood Markets rose 3.46% due to an upgrade from Piper Sandler analysts who say the company’s sudden decline gives it an attractive entry point.
  • Monday.com popped 14.78% thanks to a strong earnings report from the software maker, due in no small part to sealing the largest deal in company history.
  • Barrick Gold soared 9.36% after beating earnings estimates on both the top and bottom lines thanks to the rising price of gold.

What’s down

Here’s where the major stock benchmarks ended:

  • The S&P 500®  index (SPX)added 0.23(0.00%) to 5,344.39; the Dow Jones Industrial Average® ($DJI) fell 140.53 points (–0.36%) to 39,357.01; the NASDAQ Composite rose 35.30points (0.21%) to 16,780.61.
  • The 10-year Treasury note yield (TNX) fell three basis points to just under 3.91%.
  • The CBOE Volatility Index® (VIX) increased 0.34 points (1.67%) to 20.71.

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Stat: 8.2%. That’s the percentage of people in the US without health insurance in the first quarter of 2024. (Healthcare Dive)

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Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

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DAILY UPDATE: Lumeris Health Tech – MultiPlan, UnitedHealth, Aetna & CVS Payer Data – Stock Melt Down

Posted on May 1, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

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MAY FIRST DAY

May Day is a European festival of ancient origins marking the beginning of summer, usually celebrated on 1 May, around halfway between the Northern Hemisphere’s Spring equinox and June solstice. Festivities may also be held the night before, known as May Eve. Traditions often include gathering wildflowers and green branches, weaving floral garlands, crowning a May Queen and setting up a Maypole, May Tree or May Bush, around which people dance. Bonfires are also part of the festival in some regions.

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Here’s where the major benchmarks ended:

  • The S&P 500 index fell 80.48 points (1.6%) to 5,035.69; the Dow Jones Industrial Average® ($DJI) lost 570.17 points (1.5%) to 37,815.92, down 5% for the month; the NASDAQ Composite declined 325.26 points (2.0%) to 15,657.82.
  • The 10-year Treasury note yield jumped more than 7 basis points to 4.682%.
  • The CBOE Volatility Index® (VIX) rose 0.98 to 15.65.

Energy shares were among the weakest performers Tuesday, behind a drop in WTI Crude Oil (/CL) futures, which fell a third consecutive session and briefly dropped under $81 per barrel. The Philadelphia Oil Service Index (OSX) tumbled 4.5% to a seven-week low. The small-cap Russell 2000® Index (RUT) shed 2.1% and ended with a loss of 7.1% for the month.

But, it was a better day for Mounjaro maker Eli Lilly, which climbed nearly 6% after its popular weight loss drugs pushed it to raise its 2024 forecast.

CITE: https://www.r2library.com/Resource

Lumeris Health, a health tech company supporting value-based care operations, raised $100 million in a new funding round to support expansion.

CITE: https://tinyurl.com/2h47urt5

A class-action complaint was filed against MultiPlan and major payers like UnitedHealth Group and CVS Health’s Aetna, arguing payers’ claims data was being used to generate low reimbursement rates.

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Healthcare Corporate Business Updates

Posted on February 10, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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Walgreens tapped Mary Langowski, a former CVS Health executive, to lead its U.S. healthcare segment. The move comes as the retail pharmacy giant looks to boost profitability in its healthcare business.

CVS Health cut its outlook for 2024 on the back of higher medical costs in the fourth quarter. The drugstore chain, which owns Aetna, joins other healthcare companies to see a spike in utilization.

And … following up on a federal law passed in September to increase competition among organ transplant contractors, HRSA is issuing requests for proposals for several different contracts.

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The UK Questions Microsoft & OpenAI as Aetna Medicaid Aids Hungry Homeless

Posted on December 12, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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United Kingdom Regulators Looking into Microsoft’s Partnership with OpenAI

A British watchdog is asking for feedback on whether Microsoft’s $13 billion, 49% stake in the ChatGPT-maker’s for-profit division constitutes a merger, the WSJ just eported. So, if the agency decides to launch a formal investigation into whether the partnership creates an unfair advantage in the artificial intelligence industry, it could eventually force the companies to change how they operate.

And, following OpenAI’s dramatic firing and rehiring of CEO Sam Altman last month, Microsoft was given a “nonvoting observer” seat on the OpenAI board.

CITE: https://www.r2library.com/Resource

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Aetna Better Health of Georgia has invested $510,000 in 17 local organizations that offer services for individuals experiencing food insecurity and homelessness across the state of Georgia.

“A holistic approach to health care starts with ensuring each individual has stable and consistent access to healthy, nutritious foods, as well as a safe place to live,” said Sonya Nelson, division president at Aetna Medicaid. “By partnering with local organizations committed to improving the quality of life for all Georgians, we can help ensure people’s most basic needs are fulfilled and they’re able to prioritize care for themselves and their families.”

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“BREAKING NEWS” Cigna and Humana to Merge?

Posted on November 30, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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Cigna and Humana are in talks for a combination that would create a new powerhouse in the health-insurance industry. The companies are discussing a stock-and-cash deal that could be finalized by the end of the year, assuming the talks don’t fall apart.

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A combination of the managed-care providers would be huge, given Cigna’s market value Wednesday morning of about $83 billion and Humana’s of roughly $62 billion.

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Cigna and Humana previously explored merging in 2015, but Humana instead struck a deal with another rival, Aetna, that was blocked by a judge on antitrust grounds, leaving Aetna to be scooped up by CVS in 2018. Another deal that would have combined Cigna with Anthem, now known as Elevance Health, also died after an adverse antitrust ruling.

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Editor’s Note: Medicare Advantage plans are pretty popular with both lawmakers and ordinary Americans — they now enroll about 31 million people, representing just over half of everyone in Medicare, by KFF’s count. Across the country, doctors are grumbling about claim denials and onerous pre-approval requirements by Medicare Advantage plans. Some hospitals and physician practices are so fed up they’re refusing to accept the plans — even big ones like those offered by United Healthcare, Cigna and Humana.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

And, just last week, the industry’s largest lobbying group, the American Hospital Association, fired off a letter to the Centers for Medicare and Medicaid Services warning that some insurers seem intent on circumventing new rules put in place by the Biden administration aimed at reining in some prior authorization and claim denials.

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PODCAST: Medicare Traditional [A and B] v. Advantage [C] v. Part [D] v. Supplements

Posted on January 23, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Eric Bricker MD

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ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

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What Doctors Must Do to File an AETNA® Medical Claim to Get Paid?

Posted on November 12, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

WITH ADJUDICATION CONSIDERATIONS

By Anonymous MD

Now you will learn and know just one reason why doctors are pulling their hair out, felling stress, burn out and may even consider suicide?

Only 54 pages of steps for one electronic claim.

READ: https://www.aetnabetterhealth.com/florida/assets/pdf/provider/Claims%20Training%20Powerpoint1.pdf

  AETNA® – We are NOT glad we met ya!

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PODCAST: Health Insurance Customer Service Rankings

Posted on July 15, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

INDUSTRY RANKINGS

According to Forrester Research, Health Insurance Customer Service is Ranked 15th Out of 19 Industries.

Image result for eric bricker

BY DR. ERIC BRICKER MD

Specifically, Forrester Research Says That Customer Service is ‘Poor’ at Blue Cross of Texas and Illinois, Blue Shield of California, CareFirst Blue Cross, Anthem, United Healthcare, Cigna and Aetna.

Hospital Billing Customer Services Is Bad Too.

Hospital Billing Complexity is So Troublesome to Patients, that 40% Say They Avoid Preventive Care and Screening Tests Just to Avoid the Billing Headache.

Healthcare Customer Service is Terrible Because Health Insurance Companies and Hospitals Do Not Need Good Billing Customer Service to Be Successful, As Demonstrated by High and Rising Health Insurance Stock Prices and Large and Growing Hospital System Revenue.

For Health Insurance Companies and Hospitals, Not Fixing Their Poor Customer Service May Be a Calculated Business Decision.

Implications: To Help Make Their Employees’ Lives Better, Employers May Need to 1) Hire a Healthcare Navigation Company or 2) Deliver More Care to Their Plan Members Outside of the Traditional Health Insurance and Hospital Systems… and Avoid the Terrible Customer Service All Together.

Disclaimer: Dr. Bricker is the Chief Medical Officer of Virtual Care Company First Stop Health and is the Former Co-Founder of Compass Professional Health Services.

Your thoughts and comments are appreciated.

THANK YOU

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FTC to Probe Physician Practice Consolidation

Posted on May 3, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

Requests 6 years of patient-level claims data from insurers

By Ryan Basen,

The Federal Trade Commission (FTC) recently announced plans to examine the consequences of physician group consolidation with healthcare facilities.

The agency said it had sent orders for 6 years’ worth of patient claims data to six insurers to inform this review: Cigna, United Healthcare, Anthem, Florida Blue, Aetna, and Health Care Service Corporation.

Consolidation of US Physician Practices Continues to Surge

LINK: https://www.medpagetoday.com/practicemanagement/practicemanagement/90792?xid=nl_mpt_DHE_2021-01-21&eun=g1650026d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Top%20Cat%20HeC%20%202021-01-21&utm_term=NL_Daily_DHE_dual-gmail-definition.

Your thoughts are appreciated.

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On Spotting Medical Billing Errors – For Patients

Posted on November 6, 2017 by Dr. David Edward Marcinko MBA MEd CMP™

Are you over-paying?

By Aetna

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Why Health Insurance Companies Fail To Generate Significant Reach with Their App Portfolio

Posted on May 2, 2015 by Dr. David Edward Marcinko MBA MEd CMP™

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The “Health Insurance App Benchmarking Report for 2015”

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AN ME-P SPECIAL REPORT

By Ralf Gordon Jahns

rgj@research2guidance.com

The majority of health insurance companies can be described as hesitant in their app publishing activities, even those that have a larger app portfolio fail to have a significant impact. A new report from research2guidance analyses global app publishing activities of the leading health insurance companies.

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Some of the reasons are that health insurance companies are not leveraging their assets, their apps are not compliant with state-of-the-art app publishing rules and missing cross promotion.

The vast majority of health insurance companies have failed to generate a significant reach with their app portfolio, with 67% of health insurance companies having achieved less than 100,000 downloads. The majority of apps in the portfolio of healthcare payers belong to the long-tail:

  • 70% of health insurance companies can be described as hesitant publishing only 1 or 2 apps. However, if health insurance companies were to publish more apps they wouldn’t necessarily generate higher download numbers.
  • 77% of health insurance companies belong to the low impact category having published less than average apps with less than average download numbers. Only 9% of health insurance app publishers could be described as active with above average impact.

AETNA

Aetna is the one health insurance company that stands out. Having published 28 apps across both iOS and Android Aetna have achieved more than 14million downloads, significantly more than any other health insurance company. That being said 85% of those download come from just on app within their app portfolio, iTriage. This is not uncommon amongst those health insurance companies that have generated a large number of downloads.

For example, 7 of the top 10 biggest health insurance companiesapp portfolios generate more than 50% of downloads from the top performing app. What are the reasons for the little impact the traditional payers of the healthcare systems have in the app economy?

RESULTS

These are some findings from research2guidance’s latest report “Health Insurance App Benchmarking 2015”. The report provides information on app categories health insurance companies concentrate on, the number of apps they have published, target user groups and the organization of their app business model.

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cell

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The study results indicate that:

  • Most health insurance companies fail to produce ‘state of the art’ apps – Apps in most cases do not incorporate the 6 key elements of best practice: Tracking and coaching, automated input, remote consultation, secure use of mHealth data, integrating their solutions into the current IT healthcare infrastructure and beautiful design and usability.
  • Companies fail to realize the potential of app integrated incentive schemes – Health insurance companies are best positioned to link financial rewards via incentive schemes to healthy and cost saving behavior of their members. However, currently there are only a few companies that link healthy behavior to financial rewards with the help of an app.
  • Health insurance companies fail to successfully cross-promote their app portfolio– Companies do not successfully leverage their app portfolio through cross-promotion. Best practice mHealth app publishers manage to have almost equally successful apps in their portfolio by cross promotion using for example, “more apps” screens, pop-ups and push notifications. This is not being done at all by health insurance companies.

More:

Conclusion

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How I Lost my Battle Against the NPI

Posted on January 24, 2013 by Dr. David Edward Marcinko MBA MEd CMP™

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Refusing a National Provider Identifier Number

By Darrell K. Pruitt DDS

pruittI can no longer refuse to apply for a National Provider Identifier (NPI). I lost that long battle. Anyone rejoicing?

I’m spent. My leverage has vanished. Telling insurers “I have no NPI” held much more inherent power than “I have an NPI but I won’t share it with you on principle.” Far too many words. My profession has become dominated by unresponsive, unaccountable 3rd parties that dental leaders in the ADA welcome as policy. Working together, they promote and commandeer the technology dentists purchase and clueless patients pay for in increased fees. I have painfully learned that principles are only for dentists who can still afford them, and it’s a bad economy for luxuries.

Non-HIPAA Entity

Since I am not a HIPAA-covered entity and therefore not required by law to adopt an NPI, my capitulation to extortion disappoints me as an American citizen. I still find it hard to believe that an anti-consumer HIPAA rule enthusiastically enforced by the dental benefits industry could force me to “volunteer” for a PERMANENT identifier. As I and 96% of dentists become jerked around by our NPIs, I hope dental historians note that I am the ONLY dentist who publicly asked “Why?” instead of “Why not?” After 6 years, I’m still awaiting an answer to that question from leaders who continue to promote the NPI to dentists while ignoring their questions.

Dental Benefits Providers

I was able to hold out up until Aetna, Delta Dental and other dental benefits providers deprived my office of access to details of patients’ dental benefits unless I have an NPI. I’m waiting for someone – anyone – to tell me how the identifier can possibly improve the dental care of those who pay Aetna and Delta Dental premiums, especially if their benefits are intentionally kept secret from their dentists. I am certain that if the nation’s employers who purchase dental benefits were aware of the transparent nonsense, they would never purchase such products. Where’s the US Chamber of Commerce? Where’s the FTC? How about the US Constitution?

This is exactly why there needs to be more openness in our profession, Doc. The cockroaches who were invited to quietly overrun dentistry cannot withstand transparency, yet I don’t know how much longer I can fight for it without further risking the health of my practice.

As anyone can understand – and as anticipated by corporate executives in the insurance industry as well as by those with vested interests in the ADA Department of Dental Informatics – to have to explain to new patients why I cannot estimate how much they will owe for treatment would destroy my practice. Outside the US, other societies deem it unethical to deny patients informed consent to treatment for any reason. The NPI is such an egregious blunder that I never expect those who promoted to accept ownership.

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NPI

Assessment

If I lost the battle, who won? Do EDR enthusiasts in the ADA call this a glorious victory and a likely source of ADA pride for decades to come? Or is it much more shameful? Since I lost freedom, I want to know who won?

Conclusion

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Direct Reimbursement [DR] and RiskManagers.Us

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Transparent Dental Benefits versus Confusion

[By Darrell K. Pruitt; DDS]

pruitt

“If you are not a part of the solution, there is good money to be made prolonging the problem.” 

Company slogan- www.riskmanagers.us

Meet Mr. William Rusteberg

Today, I met William Rusteberg on the PennWell forum when he replied to the thread, “Why the long NPI, BCBS-TX?” which I copied below, along with my response which includes a plug for Direct Reimbursement [DR].

http://community.pennwelldentalgroup.com/forum/topics/why-the-long-npi-bcbstx?page=1&commentId=2013420%3AComment%3A26976&x=1#2013420Comment26976

Mr. Rusteberg represents a company called RiskManagers.Us, whose specialty involves the benefits market, yet it is not exactly an insurance company – just like there is no such thing as true dental insurance.  RiskManagers.us is a firm that works directly with businesses to identify and develop cost-effective benefits packages – emphasizing transparency and fairness.  Now that is refreshing, friends! 

Defining RiskManagers.Us 

Here is how RiskManagers.us describes itself: 

“We do not work for an insurance company, we work for you. As an independent brokerage, and consulting firm we can represent any licensed insurance company in Texas, Colorado, Mississippi, Louisiana, Alabama, Illinois & Florida.”

If one visits the Web site’s “Reference Library,” here are some of the topics offered:

·         Self Funding – Need a second opinion?

·         Texas leads in transparency issues

·         Can’t get claim information? HB 2015 May Solve Your Problem

·         Medical Stop Loss Through a Captive

·         PPO Discounts – Games People Play

·         PPO Networks – Shell Game

·         Can Hospitals waive Deductibles in Texas?

“What is a NPI number?” 

Mr. Rusteberg’s initial question on the PennWell forum simply asked, “What is a NPI number?”  Following my explanation, he wrote: 

 “It seems that many of those in your profession would do well in accepting cash only, or directly working with employer groups who sponsor dental/medical plans on a direct pay basis. We have had good success in doing this for our clients – we have one employer in San Antonio who pays medical care providers directly and quickly – providers like it and the plan pays a fair and reasonable rate, not relying on a PPO network to “re-price” claims. We have done the same on dental plans, eliminating the insurance company, PPO network and paying dental care providers submitted charges directly and quickly. We see little or no trend increases on dental charges using this method. In my view, insurance companies interfere in patient – provider relationships in a financially detrimental way.”

Thanks for your reply.

My Response:

I like you, William; 

What you describe sounds like my all-time, personal favorite dental benefits plan. It is called Direct Reimbursement {DR}, and it not only gives the employer the unlimited capability to design a plan which reflects the level of commitment desired by the company, but most importantly, it naturally preserves quality of care by allowing employees unlimited freedom of choice in dentists.  And that’s as good as the market gets. 

http://www.directreimbursement.com/

In addition, since there are no NPI requirements for DR, employees are also permitted see dentists who decline NPI numbers for ethical reasons. That increases employees’ choice by 50% over BCBS-TX clients, according to recent information provided by the Healthcare IT Transition Group.

http://www.npidentify.com/stats.htm#states

Little Management Needed

Just like the benefits plans you mention, with DR, very little money is spent on management because such policies are so simple and transparent that there is no room for profit-enhancing (wasteful) confusion used by unethical companies like BCBSTX, Aetna, Cigna, UnitedHealth, Delta Dental, United Concordia, and so many other members of the National Association of Dental Plans (NADP).

Assessment

Without transparency and the invisible hand of freedom-of-choice, free-market competition for healthcare dollars disappears as fast as executive bonuses rise. We’ll see where it goes from here. It would sure be swell if a Direct Reimbursement representative takes interest in the conversation; anyone home? 

Conclusion

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UnitedHealth Group Shenanigans

Posted on January 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

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Ingenix’s Lack of Independence Cited

[By Dr. David Edward Marcinko; MBA]

dem2

According to Melissa Dahl, Jeff Rossen and Robert Powell of msnbc.com on Jan. 13th, 2009, UnitedHealth Group agreed to pay $50 million in a settlement after being accused of over charging millions of Americans for health care.

The Investigation

An investigation was launched after receiving hundreds of complaints about Oxford Insurance and its parent company, which claims to rely on “independent research from across the health care industry” to determine reimbursement rates.

Faux Independence

In actuality though, it relies on the well known firm, Ingenix, a research arm owned by UnitedHealth Group. The allegations are that Ingenix has been manipulating the numbers so insurance companies pay less.

Other Insurers under Investigation

Although UnitedHealth Group and Oxford Insurance were the only entities investigated, other major insurers use Ingenix, including Aetna, CIGNA and WellPoint/Empire BlueCross BlueShield.

CEO Bill McGuire

The $50 million UnitedHealth Group will pay as the settlement will be used to create a nonprofit organization that will determine reimbursement rates for patients. William W. McGuire MD was the CEO of United from 1992 until his ignominious resignation in 2006, because of his involvement in an employee stock options scandal. Hence, rise of the insider moniker; “Useless Healthcare.”

Assessment

According to blogger Robert Laszewski,

“The big losers here are the docs. The result is going to be about the same and their medical societies will now have less reason to challenge the customary and reasonable system than they did before.”

As a medical practitioner, I eschewed contracts with this company a decade ago. Relative to peers, I was never so happy! Some companies just can’t seem to learn, or change their culture. But, the more important question to ask: is this indicative of an isolated rogue company, or the entire health insurance industry?

Conclusion

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