We Call Them ‘Zero Balance Claims’

by Ryan Jerico
Senior Consultant, TFG Partners

With my Prescription Benefit, I pay a $20 copay for all generic medications. So when I go to the doctor for my yearly sinus infection each spring, things are pretty routine. She writes me a prescription for Amoxicillin.  I walk across the street into a large chain grocery store who advertises $4 for a 30 day supply of 40 different generic drugs. more

Comparing Costs Around the Globe

The International Federation of Health Plans has released its 2015 Comparative Price Report, detailing its annual survey of medical prices per unit for medication and procedures around the world. As you might expect, the United States’ pricing is highest in most cases.

Prices examined in the study included those from Australia, New Zealand, South Africa, Spain, Switzerland, United Kingdom and United States. More than 540 million medical/Rx claims were analyzed from the US alone.

Checkout the breakdown for yourself in Becker’s Hospital Review.

Filling A Prescription? You Might Be Better Off Paying Cash

By Julie Appleby for Kaiser Health News  | 

Some consumers who use health insurance copays to buy prescription drugs are paying far more than they should be and would be better off paying with cash, especially for generics.

The added cost runs as high as $30 or more per prescription, say pharmacists, and the money is largely being pocketed by middlemen who collect the added profit from local pharmacies.

Cash prices started to dip below copays a decade ago when several big box stores started offering dozens of generics for as little as $4 per prescription. But as copays have risen and high-deductible insurance plans become more common, more consumers are now affected.

The phenomenon illustrates the complexity of how drugs are priced in the U.S. and has led to finger-pointing about who is benefiting or who’s to blame. more

A New Bariatric Approach – A Valve in Your Stomach


According to an article posted on CNBC.com today, AspireBariatrics has received FDA approval for it’s AspireAssit device. The AspireAssit device allows the patient to discard 30% of the calories they have consumed from a recent meal directly into  the toilet.  With this interesting approach to surgical weight loss, participants in the clinical trial lost an average of 12.1 percent of their body fat in a year.

We will be interested to see how insurers and employers approach paying for this device as some professionals consider the device an “enabling device” as opposed to something helpful or behavior modifying,

Read Robert Ferris’ article “The FDA-approved a weightloss device that sucks frood from your stomach” on CNBC.com

Plan sponsors being sued, Personally.

by Ryan Jerico
Senior Consultant, TFG Partners

Truthfully, this is not an “I told you so” situation, but…. look at Dave Chase’s piece in Forbes and well….

For many years TFG Partners has been providing clients with in-depth audits via our 100% methodology. These medical plan claims audits routinely uncover issues of Other Party Liability, Duplicates and Coding issues and Plan Benefit compliance.. While there can be significant savings from correcting these administrative weaknesses, uncovering issues surrounding provider contracts, administrator policies that conflict with the plans’s benefits documents and intent, and shifting numbers in calculations to meet discount/performance guarantees has always been particularly troubling to us as auditors. Most of the time, our clients have shared our concerns and moved forward to have these issues corrected and recover dollars to the plan. We have also seen plan sponsors fail to act on the information presented.

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Increasing Drug Costs – What Should We Believe?

by Dr. Franco Mueller, MD
Partner/Medical Director, TFG Partners

According to a recent article in the New York Times by Katie Thomas on April 27, 2016, drug costs rose about 12% in 2016. However, according to research firm IMS Health, net prices — what insurers and employers actually paid — grew only about 2.8%, the lowest rate in years. The article points out that insurers and others say that lower figure obscures the larger price increases in specific areas like cancer treatment, medications-257333_640where less competition exists and it is more difficult to pit manufacturers against one another. Indeed, drug makers do profit from raising their list prices because rebates and discounts are often based on a percentage of those prices. The article then quotes Steve Miller, chief medical officer of Express Scripts “That’s where the real angst in the marketplace is.”

Chief financial officers, responsible for budgeting and paying for employee drug benefits, and human resource managers, responsible for designing the benefits, will ask: “How this difference between 12% and 2.8% is possible? How are these price increases measured?” When looking at total drug benefit costs companies are paying for employees, the 2015 increase is certainly greater than 2014’s 10% even when factoring in rebates. more

Leapfrog: Hospitals in New England lead in patient safety


Leapfrog Group
recently released its Spring 2016 Hospital Safety Scores indicating hospitals in Vermont, Rhode Island, and Maine have the top grades in hospital quality. Almost 800 participating hospitals nationwide scored an ‘A’ grade, while 15 received an ‘F’ . 

The Leapfrog Group is a nonprofit organization created by national purchasers and employers with the goal of driving quality improvements at facilities nationally.

Head over to Healthcare Finance and see the interactive map they have created visualizing the quality results.