DAILY UPDATE: GENIUS Act Protects Consumers

Posted on June 22, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

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The FTC’s second interim staff report on consolidated pharmacy benefit managers (PBMs) found that the three largest of these middlemen—CVS Health’s Caremark Rx, Cigna Group’s Express Scripts, and UnitedHealth Group’s OptumRx—”marked up two specialty generic cancer drugs by thousands of percent and then paid their affiliated pharmacies hundreds of millions of dollars of dispensing revenue in excess of estimated acquisition costs for each drug annually.”

GENIUS Act: https://www.banking.senate.gov/newsroom/majority/fact-sheet-the-genius-act-protects-consumers

CITE: https://tinyurl.com/tj8smmes

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DAILY UPDATE: PBM Mark-Ups as Stock Markets End Mixed

Posted on June 21, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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The FTC’s second interim staff report on consolidated pharmacy benefit managers (PBMs) found that the three largest of these middlemen—CVS Health’s Caremark Rx, Cigna Group’s Express Scripts, and UnitedHealth Group’s OptumRx—”marked up two specialty generic cancer drugs by thousands of percent and then paid their affiliated pharmacies hundreds of millions of dollars of dispensing revenue in excess of estimated acquisition costs for each drug annually.”

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

🟢 What’s up

  • Circle continued its stunning climb, rising another 20.69% following the Senate’s passage of the GENIUS Act earlier this week. Former toy company and soon-to-be crypto stock SRM Entertainment soared 34.63% as well.
  • Darden Restaurants, Olive Garden’s parent company, rose 1.21% after it beat earnings estimates and forecast strong growth through fiscal 2026.
  • CarMax climbed 6.61% after the auto seller reported better-than-expected earnings last quarter, thanks in no small part to a 9% increase in used car sales.
  • GMS soared 23.69% thanks to a bidding war for the specialty building materials maker between QXO and Home Depot.
  • Kroger popped 9.82% after posting mixed results last quarter, but shareholders liked that the grocery chain upped its full-year sales forecast.

What’s down

  • Credit card companies slid on the news that X may roll out a physical payment card. Mastercard lost 1.13%, and Visa sank 0.57%.
  • Chip stocks fell on reports that the US is considering canceling some waivers on semiconductors sold to China. Nvidia fell 1.12%, TSMC lost 1.87%, and Marvell Technology sank 1.92%.
  • Regencell Bioscience lost another 40% as the biotech’s rapid rally continues to fizzle out.
  • Accenture fell 6.82% after the IT company reported a 6% decline in bookings last quarter, offsetting its otherwise strong earnings report.

CITE: https://tinyurl.com/tj8smmes

Stat: $1 trillion. That’s how much one analysis says the healthcare industry could lose due to the Trump administration’s “big beautiful bill.” (Modern Healthcare)

Quote: “The evidence is mounting and indisputable that MRNA vaccines cause serious harm including death, especially among young people. We have to stop giving them immediately!”—Retsef Levi, an MIT professor and one of RFK Jr.’s newly announced CDC vaccine advisors, in a pinned 2023 X post (CNN Health)

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

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DAILY UPDATE: PBMs as Markets Dip Down

Posted on June 12, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

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CVS and Cigna’s pharmacy benefit managers (PBMs), Caremark and Express Scripts, respectively, are suing Arkansas after the state signed a bill on April 16 that would ban vertical integration between PBMs and pharmacies. The companies filed two separate lawsuits on May 29th claiming the Arkansas law is unconstitutional and “unenforceable.”

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

🟢 What’s up

  • Papa John’s popped 7.45% on a report from Semafor that the pizza chain is being taken private.
  • Oklo roared 29.48% higher after the nuclear power startup announced it has been conditionally selected to provide power to an Air Force base in Alaska.
  • Dave & Buster’s Entertainment won big, jumping 17.74% after the gaming restaurant chain reported a lower-than-expected decline in same-store sales.
  • General Motors rose 1.92% on the automaker’s announcement that it will spend $4 billion to make more cars in the US.
  • SailPoint soared 14.66% after the cybersecurity company reported better-than-expected earnings last quarter and raised its fiscal forecast.
  • Rigetti Computing rose 11.39% thanks to some optimistic comments from Nvidia CEO Jensen Huang.

What’s down

  • GameStop tumbled 5.31% after the video game retailer revealed disappointing revenue growth last quarter, though it did report a profit.
  • Chewy lost 10.98% despite beating Wall Street’s forecasts last quarter, likely due to the pet food retailer’s already-sky-high share price.
  • SunRun sank 1.81% on a downgrade from Jefferies analysts, who think the solar power provider faces too many headwinds if residential demand drops.
  • GitLab plunged 10.60% after the online software developer issued a worse-than-expected revenue forecast for the coming quarter.
  • Lockheed Martin stumbled 4.26% after the Pentagon cut its order for new F-35 fighter jets in half.
  • Steel stocks took it on the chin today thanks to a report that the US and Mexico are nearing a deal that would reduce the 50% tariff on steel imports. Cleveland-Cliffs fell 8.10%, Nucor lost 6.06%, and Steel Dynamics tumbled 2.82%.

CITE: https://tinyurl.com/tj8smmes

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

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DAILY UPDATE: Federal Health Agencies and PBMs as Technology Stock Plunge!

Posted on January 28, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Federal health agencies are canceled—well, their meetings are at least. In the days following his inauguration, President Donald Trump’s administration asked officials within the Department of Health and Human Services (HHS)—which has a $1.7 trillion budget and includes the FDA, the CDC, and the National Institutes of Health (NIH)—to stop all external communication, according to an internal memo. This means no new health advisories, social media posts, or website posts.

“As the new administration considers its plan for managing the federal policy and public communications processes, it is important that the president’s appointees and designees have the opportunity to review and approve any regulations, guidance documents, and other public documents and communications (including social media),” the memo read. The pause began on Jan. 21st, and according to the memo, will remain in effect until Feb. 1st

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

The FTC’s second interim staff report on consolidated pharmacy benefit managers (PBMs) found that the three largest of these middlemen—CVS Health’s Caremark Rx, Cigna Group’s Express Scripts, and UnitedHealth Group’s OptumRx—”marked up two specialty generic cancer drugs by thousands of percent and then paid their affiliated pharmacies hundreds of millions of dollars of dispensing revenue in excess of estimated acquisition costs for each drug annually.”

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

The NASDAQ tanked on Monday as a Chinese startup rattled faith in US leadership and profitability in AI, taking a hammer to Nvidia (NVDA), wiping out a record $589 billion in market value. The NASDAQ Composite (^IXIC) sank more than 3%, while the S&P 500 (^GSPC) dropped nearly 1.5%. The blue-chip Dow Jones Industrial Average (^DJI), which is less dependent tech stocks gained more than 0.6% as investors flocked to defensive sectors. Shares of Apple (AAPL) and software giant Salesforce (CRM) also bucked the tech rout.

CITE: https://tinyurl.com/tj8smmes

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

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DAILY UPDATE: PBM Mark-Ups as Stocks Waiver

Posted on January 17, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

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The FTC’s second interim staff report on consolidated pharmacy benefit managers (PBMs) found that the three largest of these middlemen—CVS Health’s Caremark Rx, Cigna Group’s Express Scripts, and UnitedHealth Group’s OptumRx—”marked up two specialty generic cancer drugs by thousands of percent and then paid their affiliated pharmacies hundreds of millions of dollars of dispensing revenue in excess of estimated acquisition costs for each drug annually.”

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

The S&P 500 fell 0.2%. The NASDAQ 100 lost 0.7%. The Dow Jones Industrial Average slid 0.2%. A gauge of the “Magnificent Seven” megacaps slipped 1.9%. The Russell 2000 added 0.2%. The KBW Bank Index declined 0.2%.

The yield on 10-year Treasuries declined four basis points to 4.61%. The Bloomberg Dollar Spot Index rose 0.1%.

CITE: https://tinyurl.com/tj8smmes

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

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DAILY UPDATE: PBMs and Healthcare A.I. as All Major Market Indexes Drop

Posted on December 18, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Stat: 97%. That’s how many healthcare leaders think A.I. will become important in healthcare over the next five years.

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Pharmacy benefit managers (PBMs) are once again under pressure from federal leaders. A group of Democratic and Republican congresspeople proposed legislation that would attempt to prevent pharmacies from also owning PBMs. The three largest PBMs—CVS Health’s Caremark, Cigna’s Express Scripts, and UnitedHealth Group’s Optum Rx—currently operate pharmacies and administer more than 80% of the prescriptions in the US, and officials have linked this practice to drug price increases.

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

US stocks fell across the board on Tuesday, with the Dow logging its biggest losing streak in 46 years. The Dow Jones Industrial Average (^DJI) finished the session down roughly 0.6%, registering its ninth straight day of losses. The last 9-day losing streak for the Dow was Feb. 1978. Prior to that, the index suffered an 11-day losing streak in 1974 and another in 1971.

The other major indexes dropped in tandem on Tuesday, with the benchmark S&P 500 (^GSPC) falling around 0.4% and the NASDAQ Composite (^IXIC) losing about 0.3% after the tech-heavy index closed at a record high on Monday.

CITE: https://tinyurl.com/tj8smmes

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AMA: Bye-Bye Medicare Billing Codes?

Posted on November 22, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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Robert F Kennedy Jr, who was selected by Donald Trump to run the U.S. health and human services department, is working on plans to rid the American Medical Association from its role in drawing up Medicare’s billing codes, which sets doctors’ fees for more than 10,000 procedures, Oliver Barnes of The Financial Times reports.

The plan would result in an upheaval of a system that has been in place for decades. Publicly traded companies in the healthcare space include CVS Health (CVS), Centene (CNC), Cigna (CI), Elevance Health (ELV), Humana (HUM), Molina Healthcare (MOH) and UnitedHealth (UNH).

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DAILY UPDATE: United Health, Cigna and Inflation as Stock Markets Flatten

Posted on November 14, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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UnitedHealth Group posted nearly $6.1 billion in profit last quarter, edging out Elevance Health with $5.6 billion. Paige Minemyer has more takeaways from third quarter earnings results.

Cigna told investors the company is no longer pursuing a merger with Humana, opting to avoid tricky questions from federal regulators.

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

STOCKS UP

  • EV startup Rivian popped 13.71% after announcing a new $5.8 billion joint venture with Volkswagen to collaborate on a new line of vehicles that will begin rolling off the assembly line in 2027.
  • Rocket Lab…rocketed 28.44% to a new all-time high after increasing revenue 55% last quarter and announcing the first launch deal for its new Neutron rocket.
  • Charter Communications will purchase Liberty Broadband in an all-stock deal. Charter shares rose 3.63% on the news, while Liberty shares sank 5.05%.
  • Cava reported strong earnings today, including impressive same-store sales growth of 18%. Shares soared on the open, though ended the day up just 1.57%.
  • Flutter Entertainment, parent company of sports betting app FanDuel, rose 6.89% to hit an all-time high thanks to incredibly strong betting on the NFL last quarter.

STOCKS DOWN

  • The problems continue at Super Micro Computer, which announced it will need EVEN MORE time to submit its quarterly 10-Q form to the SEC. That’s on top of the delayed filing of its annual 10-K filing from back in June—and if it doesn’t file that by November 16, the stock will be delisted from the Nasdaq. Shares sank 6.31%.
  • Spirit Airlines really may go bankrupt this time. The beleaguered airline has lost hope of merging with Frontier Airlines, so shares plunged 59.32%.
  • Maplebear, which is the parent company of Instacart, delivered bad news for shareholders: Next quarter will be worse than expected. Shares fell 11.01%.
  • SoundHound AI reported record revenue last quarter, but shares plummeted 17.06% after the voice recognition stock also revealed much lower margins.

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

Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) rose 1.39 points (0.02%) to 5,985.38; the Dow Jones Industrial Average® ($DJI) added 47.21 points (0.11%) to 43,958.19; and the NASDAQ Composite® ($COMP) fell 50.66 points (–0.26%) to 19,230.74. 
  • The 10-year Treasury note yield added two basis points to 4.45%, just below last week’s four-month high.
  • The CBOE Volatility Index® (VIX) slid to 14.03, down sharply from above 20 early last week.

CITE: https://tinyurl.com/tj8smmes

The Labor Department on Wednesday reported that consumer prices in October rose 2.6% from a year earlier. That marks a pickup in the pace of inflation from September, when prices were up 2.4% on the year.

A digital token inspired by a Shiba Inu dog meme is now worth more than the company that pioneered the assembly line. Yesterday, dogecoin continued its post-election surge to become more valuable than 121-year-old Ford.

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

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Dental Managed Care is Substandard Care

Posted on October 8, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

 Dental Managed Care [DMC] is Substandard Care – count on it!

1-darrellpruittBy D. Kellus Pruitt DDS

Have you noticed most employer-sponsored dental plans boast savings of 30% and more on dental care, without mentioning how unsustainable discounts harms their employees?

Dental Managed Care [DMC] is substandard care: Discount dentistry, like virtually all underfunded handwork, has always been substandard … Or perhaps someone would like to argue that intricate surgery in sensitive mouths of nervous patients is improved when rushed.

Discounts are popular

Those who market obscure, hard to understand managed care plans to clueless, perhaps non-caring employers, do not control the quality of the discounted dentistry they sell.

Think about it: Discount dentistry without quality control. Can you think of a worse idea in healthcare?

What’s more, not one Delta Dental, Humana or Cigna executive can be held accountable for causing harm to equally clueless dental patients through under financed dentistry they sell. Employees who must choose their dentists from preferred provider lists have forfeited freedom of choice, whether they realize it or not. Their underfunded, substandard dentistry is subsidized by tax payers as a special tax-free benefit, benefiting unaccountable third parties most of all.

For example:

  • Want to know what you get with managed care dentistry? Quick prophys. 
  • How many of you get your teeth cleaned in 30 minutes or less? Do they feel clean?

One Hour

l always allowed my hygienists 1 hour to clean patients’ teeth simply because it often takes that long to do the job right – regardless what insurers say hygienists’ time is worth. The economic climate is tough on fee-for-service.

As I am considering signing on as a preferred provider – not because I want to – I notice that the fees allowed by insurers do not cover the hourly rate of most hygienists… unless they can “clean” teeth, take x-rays, take blood pressure, go over patients’ medical history, allow time for the doctor to do a quick exam and turn around the room in less than 30 minutes.

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retro dental exam room

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Assessment 

The motto of my practice is “Dentistry Unhurried.” I don’t want to compete in a race to the bottom which uninformed dental patients always lose.

Conclusion

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DAILY UPDATE: FTC Insulin Prices, Open AI Funding, Disney Slack Hack and Private Equity Banks

Posted on September 23, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

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The Federal Trade Commission hit the three largest companies that negotiate drug prices with a lawsuit claiming they’ve artificially inflated the cost of insulin for patients. The companies—UnitedHealth Group’s Optum Rx, CVS Health’s Caremark, and Cigna’s Express Scripts—together administer ~80% of all US prescriptions, the agency said. The suit alleges they increased profits by steering patients toward higher-priced insulin with bigger rebates so they could pocket the cash that drug companies gave back.

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

OpenAI has so many interested investors it’ll have to turn some away from an expected $6.5 billion funding round that values the company at $150 billion.

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

Disney employees will have to stop using Slack in the wake of a hack that leaked the company’s chat logs.

CITE: https://tinyurl.com/tj8smmes

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MEDICARE PART C: Humana Used A.I. Tool from UnitedHealth to Deny Medicare Advantage Claims

Posted on April 30, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

LAWSUIT

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Humana Used AI Tool from UnitedHealth to Deny Medicare Advantage Claims 

Humana used an artificial intelligence tool owned by UnitedHealth Group to wrongfully deny Medicare Advantage [Part C] members’ medical claims, according to a class-action complaint filed on Dec. 12th. The lawsuit was filed in the U.S. District Court for the Western District of Kentucky and is the latest legal action against major insurers such as UnitedHealthcare and Cigna for allegedly using automated data tools to wrongfully deny members’ claims.

The complaint against Humana, the country’s second-largest Medicare Advantage insurer, accuses the company of using an AI tool called nH Predict to determine how long a patient will need to remain in post-acute care and overrides physicians’ determinations for the patient. The plaintiffs claim Humana set a goal to keep post-acute facility stay lengths for MA members within 1% of nH Predict’s estimations. Employees who deviate from the algorithm’s estimates are “disciplined and terminated, regardless of whether a patient requires more care,” the lawsuit alleges. When decisions made by the algorithm are appealed, they are allegedly overturned 90% of the time.

Source: Jakob Emerson  Becker’s Payer Issues [12/13/23]

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Cigna Sells Medicare Part C as 23andMe Crashes

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

By Staff Reporters

HCSC will acquire Cigna’s Medicare Advantage, Part D, supplemental benefits and CareAllies businesses, and the parties expect the deal to close in the first quarter of 2025. And, as January exits, we enter the thick of earnings call season. This week executives at AbbVie, Cigna, and Merck—to name a few—will brief healthcare investors on how their companies fared in 2023, and provide insights on what to expect in 2024.

And, Anne Wojcicki’s billions have vanished. 23andMe’s valuation has crashed 98% from its peak and NASDAQ has threatened to delist its sub-$1 stock. Wojcicki reduced staff by a quarter last year through three rounds of layoffs and a subsidiary sale. The company has never made a profit and is burning cash so quickly it could run out by 2025.

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

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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.

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

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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MEDICARE ADVANTAGE PLANS: Part C Plans Down AS Cigna Pays Up?

Posted on October 3, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

Hospitals are Dropping Medicare Advantage [Part C] Plans – Left and Right

By Dr. David Edward Marcinko MBA

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Hospitals Say Bye-Bye?

Medicare Advantage provides health coverage to more than half of the nation’s seniors, but a growing number of hospitals and health systems nationwide are pushing back and dropping the private plans altogether. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.

“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.” Van Gorder said the health system is facing a loss of $75 million this year on the MA contracts, which will end December 31st for patients covered by UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Centene’s Health Net and a few more smaller carriers.

Source: Becker’s Hospital Review [9/27/23]

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Cigna to Pay $172M Over Alleged Medicare Advantage Fraud

The Cigna Group will pay $172.3 million to resolve allegations that it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher payments from the agency. The U.S. Attorney’s Office for the Eastern District of Pennsylvania alleged Sept. 30 that Cigna also falsely certified that the submitted data was accurate, failed to withdraw the “untruthful” data, and did not repay CMS.

Cigna will use $135.3 million from the settlement to resolve the allegations from the Justice Department. The remaining $37 million will resolve allegations related to unsupported diagnoses for Medicare Advantage enrollees that received in-home services from Cigna. As part of the settlement, Cigna has entered into a five-year accountability and auditing agreement with HHS’ Office of Inspector General, which will require company executives and board members to certify Cigna’s compliance moving forward. The payer must also conduct annual risk assessments and submit to independent risk adjustment audits.

Source: Jakob Emerson, Becker’s Payer Issues [10/2/23]

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CIGNA: Busted PxDx [Procedure-to-Diagnose]

Posted on July 26, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Dr. David Edward Marcinko MBA CMP

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(AP) — A federal lawsuit alleges that health insurance giant CIGNA used a computer algorithm to automatically reject hundreds of thousands of patient claims without examining them individually as required by California law.

RELATED: https://medicalexecutivepost.com/2022/09/18/ama-joins-class-action-suit-against-cigna/

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The class-action lawsuit, just filed in federal court in Sacramento, says CIGNA Corp. and CIGNA Health and Life Insurance Co. rejected more than 300,000 payment claims in just two months last year.

RELATED: https://medicalexecutivepost.com/2022/07/21/my-conversation-with-an-anonymous-cigna-representative/

The company used an algorithm called PXDX, shorthand for ”procedure-to-diagnosis,” to identify whether claims met certain requirements, spending an average of just 1.2 seconds on each review, according to the lawsuit.

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

Huge batches of claims were then sent on to doctors who signed off on the denials, the lawsuit said.

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PODCAST: https://medicalexecutivepost.com/2023/07/01/podcast-the-cigna-group-ceo/

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PODCAST: The CIGNA Group CEO

Posted on July 1, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

Health Unscripted Podcast: Lessons from a purpose-driven CEO featuring David Cordani

LISTEN: https://tinyurl.com/bddj8bud

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CIGNA Healthcare Truth

Posted on March 19, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Darrell K. Pruitt DDS

QUOTE: “Employees are the biggest asset of any company, so it’s more important than ever to focus on staff well-being during uncertain times.”

Jason Sadler – President, International Health

Cigna Healthcare

QUERIES: So, Jason Sadler, how do you think Cigna’s dentists feel about Cigna?

Do you even dare to publicly respond to that question? … I didn’t think so.

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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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CIGNA Healthcare Truth

Posted on March 18, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Darrell K. Pruitt DDS

QUOTE: “Employees are the biggest asset of any company, so it’s more important than ever to focus on staff well-being during uncertain times.”

Jason Sadler – President, International Health

Cigna Healthcare

QUERIES: So, Jason Sadler, how do you think Cigna’s dentists feel about Cigna?

Do you even dare to publicly respond to that question? … I didn’t think so.

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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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The Benefits of Dentistry Unhurried

Posted on November 30, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

And Medicine, too?

[By Kellus Pruitt DDS]

1-darrellpruittThe hidden truth about managed care dentistry: Unhurried dentistry is generally of higher quality than hurried dentistry; anyone up to challenging this economic law?

Dental Handiwork

Dental care includes intricate handwork performed to exacting tolerances in sensitive mouths of nervous patients. When dentists compete on discounts (fast dentistry) instead of quality (slow dentistry), fear of bankruptcy fuels the race to the bottom with clueless, vulnerable patients.

 “‘Slow medicine’ strikes a chord – Nearly 500 people — doctors, nurses and ordinary people with an interest in health care — attended a forum Thursday to hear Dr. Victoria Sweet, a physician and author, talk about how ‘slow medicine’ could improve the quality of life of patients. Sweet is Associate Clinical Professor of Medicine at University of California, San Francisco.”

Melinda Morales for the Visalia Times-Delta

[Visalia, California – October 16, 2014]

http://www.visaliatimesdelta.com/story/news/local/2014/10/17/slow-medicine-strikes-chord/17400861/

Morales writes: “When Sweet told the audience she had once wondered to herself, ‘If I could do one thing to improve the quality of health care, what would it be?’ and then followed it up with her solution, ‘I would put time back into the hands of physicians,’ the audience burst into applause.”

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Insightful or clueless dentist?

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Enjoy the Teeth

Dentistry is far more enjoyable for all concerned when it is not rushed in order to squeeze out a profit from unsustainable pay offered by unaccountable, conniving discount dentistry brokers … like CIGNA.

“Cigna to launch rating system that ADA calls scientifically flawed – Cigna will launch in 2015 what it calls a cost-effectiveness designation program that rates in-network dentists based on cost and utilization patterns. These ratings will appear as stars within Cigna’s provider directory. According to Cigna, dentists who receive a three-star rating have a fee schedule that results in greater potential cost savings within their geographical area.”

Kelly Soderlund

[ADA News, October 13, 2014]

Good reporting, ADA News

This isn’t the first time CIGNA has been busted for selling intentionally misinformed, captive patients discount healthcare with no quality control – depriving Americans of the opportunity to choose providers which most patients prefer. Seven years ago, CIGNA and other insurers were reprimanded for employing Ingenix, UnitedHealth Group’s wholly-owned ranking algorithm designed to drive clients from out-of-network providers to cheaper in-network providers:

“Attorney General Cuomo Announces Agreement With Cigna Creating A New National Model For Doctor Ranking Programs – NEW YORK, NY (October 29, 2007) – Attorney General Andrew M. Cuomo today announced an agreement with one of the nation’s largest health insurers, CIGNA HealthCare (NYSE: CI), as part of his industry-wide investigation into doctor ranking programs. Under the agreement, CIGNA will enhance its doctor ranking program, fully disclosing to consumers and physicians all aspects of its ranking system. Additionally, CIGNA will retain an oversight monitor known as a Ratings Examiner (‘Rx’) who will oversee compliance with all aspects of the agreement and will report to the Attorney General every six months.”

Eric T. Schneiderman

[Office of Current NY State Attorney General]

http://www.ag.ny.gov/press-release/attorney-general-cuomo-announces-agreement-cigna-creating-new-national-model-doctor

See also, “UnitedHealth Group Shenanigans – Ingenix’s Lack of Independence”

Dr. David Edward Marcinko MBA

[Medical Executive-Post, January 16, 2009]

https://medicalexecutivepost.com/2009/01/16/unitedhealth-group-shenanigans/

As you can see, history reveals that Cuomo fruitlessly reminded CIGNA that price is only one variable in “cost-effectiveness.” As dentists and their patients know, correcting careless mistakes is always more costly than doing the job right the first time with the best materials for reasonable pay.

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slow down

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CIGNA Speaks

Cigna spokeswoman Karen Eldred tells ADA News,

“Cigna remains committed to introducing enhancements to the mycigna.com’s dental network directory that provide customers with cost [but not quality] transparency and insights when using their dental benefits.”

If anyone in the ADA is allowed to consider non-member dentists’ advice, I would recommend publicly confronting CIGNA with an easy to document comparison of the popularity of CIGNA’s one, two and three star, cost-effective dentists with competitors using doctoroogle.com – arguably the most transparent dentist-rating site in the nation.

http://texas.doctoroogle.com/

Anyone who is interested in performing the simple, consumer-friendly study is almost certain to discover a direct correlation between the amount of time dentists can afford to invest in their work and their preference by patients in the community.

More:

Assessment

Have you ever experienced a cost-effective injection of local anesthetic?

Hurried Care?

Conclusion

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AMA Joins Class-Action Suit Against CIGNA

Posted on September 18, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

By Paige Minemyer

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The AMA and 2 State Medical Societies Join Class-Action Suit Against CIGNA

The American Medical Association (AMA) has joined a class-action lawsuit against Cigna, alleging the insurer underpaid for claims filed by providers in the contracted MultiPlan network. MultiPlan is the country’s largest third-party network, and Cigna contracts with it to access providers. According to the lawsuit, which was initially filed in June, Cigna reimbursed for claims from providers in MultiPlan’s network at its non-participating providers rate rather than at the rate expected for a MultiPlan contract.

As such, the insurer “significantly underpaid claims, and put patients at risk of balance billing,” the plaintiffs claim. “It also breached its fiduciary duties, including its duty to honor written plan terms and its duty of loyalty, because its conduct serves Cigna’s own economic self-interest and elevates Cigna’s interests above the interests of plan member patients,” according to the lawsuit.

Paige Minemyer, Fierce Healthcare [9/13/22]

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My Conversation with an Anonymous Cigna Representative

Posted on July 21, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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Cigna, do you even have a clue that dentists don’t like you?

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By Darrell K. Pruitt DDS

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Hi Dr. Pruitt,

I’m truly sorry for any negative experience you’ve encountered with us. Is there a claim, benefit, or authorization concern I can help with? Please email me at LetUsHelpU@cigna.com. I’d like an opportunity to assist.

At a time when interest rates are surging, and just when I request an increase, CIGNA REDUCED MY REIMBURSEMENTS! Never again will I do business with you, and will discourage other dentists from falling into your trap …. And that is why dentists don’t like #TeamCigna. 

What is your name, anyway. You know mine. Perhaps Linkedin’s transparency makes it a poor choice for marketing Cigna.

As if things could get no worse between Cigna and dentists, you censored my response!

NOTE: Cigna representatives prefer to remain anonymous for reasons of accountability.

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BUSINESS MEDICINE: https://www.amazon.com/Business-Medical-Practice-Transformational-Doctors/dp/0826105750/ref=sr_1_9?ie=UTF8&qid=1448163039&sr=8-9&keywords=david+marcinko

Health Insurance: 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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IMHO @TeamCigna Should Treat their Dentists Better!

Posted on June 30, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Darrell Pruitt DDS

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“How Is The Market Feeling About Cigna?” Spoiler – According to Benzinga insights, the market is not optimistic about Cigna’s future. Neither am I. But then, I’m only their clients’ dentist.

Link: https://www.benzinga.com/short-sellers/22/06/27888029/how-is-the-market-feeling-about-cigna

Tomorrow is my last day as a Cigna Preferred Provider .. Never Again!

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PODCAST: Pharma Rebates to PBMs

Posted on January 15, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

Pharma ‘Rebate’ Payments to PBMs No Longer Protected by Federal ‘Safe Harbor’

BY DR. ERIC BRICKER MD

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HEALTH ECONOMICS CITE: https://www.r2library.com/Resource/Title/0826102549

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PODCAST: CIGNA Executive Public Relations “Whistle Blower”

Posted on December 29, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

Wendell Potter is a Famous Ex-Executive from Cigna Who Left His High Paying PR Job in 2007 to Reveal the True Story Behind Health Insurance Carrier Public Relations.

BY ERIC BRICKER MD

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PODCASTS: How Prescription [Rx] Coverage Works

Posted on December 19, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

Formulary Tiers, PBM, Rebates, Spread-Pricing Explained

By Dr. Eric Bricker MD

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CITE: https://www.r2library.com/Resource/Title/082610254

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PODCAST: Shareholder Activism in Healthcare

Posted on August 9, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

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BY DR. ERIC BRICKER MD

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Your thoughts and comments are appreciated.

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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.

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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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Direct Reimbursement [DR] and RiskManagers.Us

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

Join Our Mailing List

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]

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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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