Articles Tagged with: Health Benefits
Home / Blog Archives

How To Win The Battle Against High Deductibles

We’ve been sold a story. A story spun by big insurance companies and the healthcare industry, promising us a path to smarter, more cost-effective healthcare. They told us that high deductibles would make us better consumers, more careful with our healthcare dollars.

The idea sounded appealing on the surface: a little more responsibility, a little more “skin in the game,” and we’d all be savvy healthcare shoppers.

But here’s the thing: how can you be smart when you’re shopping blindfolded?

Imagine walking into a store. There are no price tags, no labels, just a shelf full of mystery boxes. “Don’t worry,” they tell you, “you’re covered after the first $5,000!” Would you feel empowered? Or trapped? That’s exactly what healthcare with high deductibles and no transparency looks like. And that’s what we’ve been sold—by both the healthcare system and the big insurance companies.

We wouldn’t accept this anywhere else. Not for buying a car, a house, or even a sandwich. But somehow, when it comes to our healthcare—the most important decisions affecting our well-being—we’re expected to navigate in the dark.

High deductibles were supposed to be the silver bullet to fix skyrocketing healthcare costs. They were supposed to make us all better, smarter consumers. Instead, they’ve just added another layer of confusion to an already baffling system.

Here’s the reality: they tell us to have “skin in the game,” but it’s a game where we don’t know the rules. We don’t know the score. We don’t even know which field we’re playing on. How can you be expected to make informed decisions when you have no idea what anything costs until after the fact?

The promise was that consumer-driven healthcare was the solution, but in practice, it’s turned into consumer confusion.

And here’s the kicker—real empowerment doesn’t come from high deductibles. It comes from transparency. It comes from knowing what you’re paying for before you buy it. We don’t need bigger deductibles; we need bigger flashlights to shine a light on the system. We need to see clearly what we’re paying for, what we’re getting, and whether it’s even worth it.

That’s the change we need to demand. That’s what we should be fighting for —a healthcare system that actually works for us, not against us. A system that doesn’t hide behind layers of bureaucracy and complexity but instead gives us real visibility, real options, and real choice.

And that’s exactly what I’ve ensured with Better Source Benefits plans—no more smoke and mirrors, no more guessing games. Just clear, transparent, and fair healthcare coverage.

The choice is ours, but only if we can see it. It’s time to break through the status quo and demand a system that actually serves us—not the insurance companies. We deserve better. And it’s time we got it.


Escape the system, or just continue feeding it… Your gateway is here >> 

Hidden Costs: How Insurance Giants Overcharge Corporate Clients for Surgical Procedures

If you’ve ever turned on the TV, scrolled through social media, or flipped through a magazine, you’ve likely seen a steady stream of advertisements for medications like Restasis, Ozempic, Vraylar, Eliquis, Farxiga, Linzess, Jardiance, and Taltz. These medications promise relief from chronic conditions, improved quality of life, and better health outcomes. But they come with a hefty price tag, and for many companies providing healthcare benefits, these high-cost medications are wreaking havoc on their bottom lines.

The problem is simple: corporate healthcare plans—often fully insured, cookie-cutter packages—are struggling to absorb the escalating costs of prescription drugs. Employers are shouldering more of the financial burden, passing rising premiums down to employees, while employees face increasingly steep out-of-pocket costs just to maintain their prescribed treatments. 

The result? Less access, lower adherence, and worse outcomes. It’s a vicious cycle.

And if you’re a member of a corporate sector – whether an employer or an employee – there’s only one way of escaping it. 

You make your own plan, with your own rules.

That’s what Better Source Benefits designs for the clients. These solutions don’t just shift the cost of healthcare—they change how it’s managed, creating opportunities for both employers and employees to save significantly, especially when it comes to high-cost medications.

Through carefully structured, deeply discounted arrangements, our custom self-funded healthcare plans allow employers to secure medications like the ones you see advertised for far less. And when we say “far less,” we don’t just mean a small percentage difference—we mean significant cost reductions that can take a meaningful chunk out of an employer’s healthcare expenses.

Let me give you just a couple of examples from our list: 

  • Glatopa: $0 instead of $750
  • Relistor: $0.00 instead of $2,314.97
  • Traltz: $0.00 instead of $6,482.52
  • Trulance: $0.00 instead of $549.31
  • Envarsus: $0.00 instead of $374.04
  • Restasis: $854 instead of $1,956.90
  • Ozempi: $1,485.00 instead of $2,719.62
  • Tradjenta: $314 instead of $1,550.70
  • Vraylar: $1,309.99 instead of $4,413.60
  • Flowent: $226.98 instead of $1,253.25

…. And that’s only the tip of the iceberg.  

I know that every employer reading this, is impressed already. But what’s truly revolutionary is how these plans can benefit employees.

We’re not just talking about lower co-pays or reduced premiums. With our solution, employees can often access these expensive medications at no cost to them. That’s right—free

Imagine getting a 90-day supply of your prescribed medication without having to worry about how much it’s going to cut into your paycheck or impact your monthly budget. Our plans make that a reality by eliminating the cost to employees while still maintaining high-quality coverage.

Access to medications for chronic conditions without financial barriers can improve patient adherence, which is crucial in managing long-term health conditions like diabetes, heart disease, mental health disorders, and autoimmune diseases. When employees can stick to their treatments without interruptions, they see better results.

That means fewer hospital visits, fewer complications, and less time spent navigating the healthcare system.

A Smart Way To Get 40% Off The High-Cost Medications

If you’ve ever turned on the TV, scrolled through social media, or flipped through a magazine, you’ve likely seen a steady stream of advertisements for medications like Restasis, Ozempic, Vraylar, Eliquis, Farxiga, Linzess, Jardiance, and Taltz. These medications promise relief from chronic conditions, improved quality of life, and better health outcomes. But they come with a hefty price tag, and for many companies providing healthcare benefits, these high-cost medications are wreaking havoc on their bottom lines.

The problem is simple: corporate healthcare plans—often fully insured, cookie-cutter packages—are struggling to absorb the escalating costs of prescription drugs. Employers are shouldering more of the financial burden, passing rising premiums down to employees, while employees face increasingly steep out-of-pocket costs just to maintain their prescribed treatments. 

The result? Less access, lower adherence, and worse outcomes. It’s a vicious cycle.

And if you’re a member of a corporate sector – whether an employer or an employee – there’s only one way of escaping it. 

You make your own plan, with your own rules.

That’s what Better Source Benefits designs for the clients. These solutions don’t just shift the cost of healthcare—they change how it’s managed, creating opportunities for both employers and employees to save significantly, especially when it comes to high-cost medications.

Through carefully structured, deeply discounted arrangements, our custom self-funded healthcare plans allow employers to secure medications like the ones you see advertised for far less. And when we say “far less,” we don’t just mean a small percentage difference—we mean significant cost reductions that can take a meaningful chunk out of an employer’s healthcare expenses.

Let me give you just a couple of examples from our list: 

  • Glatopa: $0 instead of $750
  • Relistor: $0.00 instead of $2,314.97
  • Traltz: $0.00 instead of $6,482.52
  • Trulance: $0.00 instead of $549.31
  • Envarsus: $0.00 instead of $374.04
  • Restasis: $854 instead of $1,956.90
  • Ozempi: $1,485.00 instead of $2,719.62
  • Tradjenta: $314 instead of $1,550.70
  • Vraylar: $1,309.99 instead of $4,413.60
  • Flowent: $226.98 instead of $1,253.25

…. And that’s only the tip of the iceberg.  

I know that every employer reading this, is impressed already. But what’s truly revolutionary is how these plans can benefit employees.

We’re not just talking about lower co-pays or reduced premiums. With our solution, employees can often access these expensive medications at no cost to them. That’s right—free

Imagine getting a 90-day supply of your prescribed medication without having to worry about how much it’s going to cut into your paycheck or impact your monthly budget. Our plans make that a reality by eliminating the cost to employees while still maintaining high-quality coverage.

Access to medications for chronic conditions without financial barriers can improve patient adherence, which is crucial in managing long-term health conditions like diabetes, heart disease, mental health disorders, and autoimmune diseases. When employees can stick to their treatments without interruptions, they see better results.

That means fewer hospital visits, fewer complications, and less time spent navigating the healthcare system.

Affordable Care Act Explained

So let’s talk about the Trump health plan, which they say doesn’t exist right now. And the reason for that is very simple.

The Affordable Care Act was in the can for years and it was torturously written so as not to look like a tax, which is exactly what it was ruled to be from the US Supreme Court. So the wordsmiths that are in the Swamp as we have been known to hear it called, had already cooked up the Affordable Care Act long before it was ever launched under President Obama.

So the Affordable Care Act was a carefully crafted policy that was setting our country on the rails to a single payer system. So when you have comments or questions coming to the Trump, campaign about what his plan is to replace the Affordable Care Act.

There is no replacing it. There’s a patch, there’s a workaround, or there’s a full on repeal. However, there are too many popular components of that law. The safety net is in place and I don’t foresee anything going forward that’s gonna replace the whole thing.

Now, will there be amendments? Yes.

Will there be adjustments? Yes.

Will there continue to be a public and a private offering? The magic eight ball says yes, because anywhere there’s been a publicly funded medical plan, whether it’s the US or Australia, you always see an overlay or a secondary or private healthcare plan to supplement what the government does, because guess what?

The government does not have enough money. They cannot print enough money to cover the costs of everyone’s whim and folly, which we are currently seeing with the use of this GLP -1 business. Weight loss is sweeping across the nation. Everybody’s cutting weight, even though the facts are in on the dramatic weight loss being 70 % of muscle mass as opposed to regular fat.

So the long -term effects aren’t even in place yet we have the federal drug administration, the FDA approving prescription drugs to have weight loss at a breakneck pace without the true long -term effects being studied. So I will say to you that summary for the Trump campaign versus the Harris campaign is you can expect both of them to look at the Affordable Care Act as their go -to. And for Harris, they could certainly rest on their laurels because it is working towards a single payer option. And for Trump, you can look at their campaign and if they’re elected presidency to patch and amend what is currently in place. You’ve already seen Trump try to manage the cost of prescription drugs and which…

did take effect during his administration. So that’s going, yet the drug market continues to proliferate with high cost medications because as we know, there ain’t no money in the cure, the money’s in the medicine. I’m John Clay and this is your Healthcare Minute.

Paying cash for healthcare services can often lead to lower bills compared to using insurance

High deductible plans may not always provide the best deal for consumers and their employees. Research shows that paying cash for healthcare services can often result in lower bills compared to using insurance. Insurance companies negotiate discounts off the retail price set by healthcare providers, but cash pay prices are even lower.

This discrepancy highlights the need for price transparency and better incentives to encourage people to explore lower-cost services.

The time is now. CLAIM YOUR 30 MINUTES WITH JOHN CLAY and get an option for your renewal instead of another year of increase…

 

In this episode, we discuss:

✅ Lowering Healthcare Prices with Instruments
✅ Insurance Discounts vs Cash Pay
✅ The Need for Price Transparency
✅ tDriving Transparent and Predictable Pricing

Learn how your healthcare plan can help you reach these goals in 2024

OPTIONS INSTEAD OF AN INCREASE… Claim your 30 minutes with John Clay and learn what solutions your company is eligible for in Q4/2023

 

Connected Planning and Healthcare (For The CFOs)

Increasingly, C-suite leaders are looking to connect their business plans across their finance, workforce, sales, and supply chain teams.

This approach, known as “connected planning,” provides deeper insight into data across the company so that business leaders can get a good view of the whole business plan and not just one piece of it.

Connected planning helps to improve decision-making and identify the right strategy for the business. More CFOs are now partnering with their C-suite counterparts (chief operating officers, sales leaders, etc.) to connect plans across lines of business and give executives better information company-wide.

Now, do you think CFOs should consider the second biggest operational expense in the organization, into their “connected planning” process? (crickets) – That was a rhetorical question.

There is no question about it.

This year, you’ll have to examine if your healthcare plan is part of a problem, or part of a solution to protect your organization from both internal and external threats of 2024.

The time is now. CLAIM YOUR 30 MINUTES WITH JOHN CLAY and get an option for your renewal instead of another year of increase…

 

The top 4 concerns of the CFOs in 2024 are:

✅ Cutting the right costs
✅ Budget planning
✅ Increasing profitability
✅ Attract and keep the right talent

Learn how your healthcare plan can help you reach these goals in 2024

OPTIONS INSTEAD OF AN INCREASE… Claim your 30 minutes with John Clay and learn what solutions your company is eligible for in Q4/2023

 

Awkward situation: Commercial Payers Delay Paying Out Claims To Providers

Data reveals that over three months passed without payment for thirty-one percent of inpatient claims submitted to commercial payers.

Situation

At the beginning of the year, hospitals and health systems held optimistic expectations regarding their financial performance, anticipating a rebound in revenue and profit margins following a challenging period. However, their financial situation has continued to face difficulties. A recent analysis conducted by Crowe places a significant portion of the blame on commercial payers, citing frequent initial claims denials and various obstacles hindering payments to hospitals.

Examining data from the first quarter of this year related to revenue cycle analytics, the statistics reveal that 31% of inpatient claims submitted to commercial payers remained unpaid for more than three months. In contrast, only 12% of claims submitted to traditional Medicare experienced such delays.

Similar figures emerged when assessing outpatient claims, with 32% of claims facing extended delays with commercial payers, as opposed to just 11% with Medicare.

One particularly striking metric was the rate of prior authorization and precertification denials – rejections based on the payer’s determination that a provider either did not obtain prior approval for treatment or that the treatment was not medically necessary based on the diagnosis. The incidence of these “medical necessity” denials has been on the rise for several years, and the trend persists. During the first three months of 2023, the rate of inpatient claim denials due to medical necessity reached 3.2%, in contrast to Medicare’s 0.2%. In 2021, the denial rate for such claims was 2.4%.

Although the increase may appear relatively minor, a denial based on prior authorization or precertification can trigger a significant battle to secure payment, as noted by Crowe. Providers who disagree with the denial must navigate a labor-intensive appeals process involving utilization management, nursing staff, physicians, and possibly the patient. This effort can be substantial in terms of costs, time, and complexity, often without a guarantee of full payment from the payer.

The time is now. CLAIM YOUR 30 MINUTES WITH JOHN CLAY and get an option for your renewal instead of another year of increase…

 

The Outcome

Within the realm of claim denials, the category of prior authorization and precertification denials forms a subset of a broader metric encompassing initial denials. In the first quarter of 2023, commercial payers initially rejected 15.1% of both inpatient and outpatient claims for various reasons, while the comparable figure for Medicare during the same period stood at 3.9%.

Although most claims initially denied by commercial payers eventually get resolved and paid, the administrative efforts required to turn an initial denial into a positive outcome impose substantial costs on providers, as confirmed by Crowe. This process necessitates active involvement from the provider to secure payment for the services rendered.

Another category of claim denials contributing to payment delays from commercial payers pertains to requests for information (RFI). RFI denials occur when a payer chooses not to process a claim due to the absence of essential documentation, such as an attachment, signature, or a copy of the medical record.

In terms of numbers, commercial payers exhibit a denial rate that is 12 times higher than that of Medicare. In the first quarter of 2023, the RFI denial rate for inpatient and outpatient claims submitted to commercial payers by providers was 4.8%, in contrast to Medicare’s 0.4%. Crowe notes that an RFI denial can prolong payment by at least 45 days, impacting cash flow and accounts receivable performance adversely.

OPTIONS INSTEAD OF AN INCREASE… Claim your 30 minutes with John Clay and learn what solutions your company is eligible for in Q4/2023

 

Business Lexington – July, 2023 – John Clay, BetterSourceBenefits

Breaking Through The Benefits Status Quo

Download the full article here >>

In the 1990s, while working as a benefi ts advisor for Blue Cross Blue Shield of Kentucky, John Clay realized he could do more to help his customers. Over the course of the decade, Blue Cross Blue Shield of Kentucky eventually transformed to become Anthem Blue Cross Blue Shield, transitioning from a mutual company owned by policyholders to a publicly traded company owned by stockholders. 

This change didn’t sit well with Clay. Feeling unsatisfied with simply working out renewal programs with a limited number of insurance companies, Clay joined a “mastermind group” of advisors from across the country who were dedicated to making a difference in the lives of employers and employees.

 
“I already had a background in inventory control and material management. So, we started managing the healthcare supply chain,” Clay said. “We put our custom-designed plans that were in the best interest of employers and their employees in a fiduciary or legal and ethical way.” 

In 2000, Clay, who graduated from the University of Kentucky Gatton College of Business with a degree in supply chain management, founded Better Source Benefits, a boutique healthcare benefits agency based in Somerset. Better Source Benefits operates throughout Kentucky, Ohio, Tennessee, and New York. His clients range from companies with as few as 100 employees to those with as many as 5,000 employees. 

Clay primarily serves the construction, energy, and manufacturing industries, as well as nonprofit organizations such as city and county governments. 

Clay prefers to be known as a strategy expert rather than a consultant, believing that companies need targeted strategies to break free from the status quo of rising premiums and diluted healthcare options found in many employee benefit plans. 

“Better healthcare outcomes with less risk and lower prices are what companies need,” Clay said. 

Three insurance companies dominate Kentucky’s healthcare benefit marketplace: Anthem, United Healthcare, and Humana. Recently, Humana announced its withdrawal from the Employer Group Commercial Medical Products business in the state. Clay urges CEOs and CFOs to take a more active role in selecting employee benefit plans rather than leaving it solely to the human resources director. He highlights this scenario in his book, “Breaking Through The Status Quo.” 

According to Clay, the average business owner is often uninvolved in benefit sales conversations. And while the CFOs focus on the profit and loss statement, they rarely discuss the strategic aspects of benefits plans with the HR director. As a result, the cost of available plans continues to rise, but the CFO may not recognize opportunities for improvement. 

Clay refers to this situation as the Status Quo scenario. 

In “Breaking Through The Status Quo,” author John Clay outlines alternatives to the rising premiums and diluted healthcare options found in many employee benefit plans. 

Clay said that inflation is also among the greatest challenges facing the employee benefits market in 2023. Healthcare inflation has consistently outpaced general inflation over the past 50 years, making it difficult for the employers to meet the growing demands of employees seeking more robust benefits packages, he said. 

Additionally, the employee benefits marketplace faces challenges related to the lingering economic effects of COVID-19, increased usage of prescription drugs, mental health and substance abuse issues, and advancements in medical treatments and technology. 

All of these factors lead to higher cost and diminished benefits for employees, Clay said. 

“The term Affordable Care Act is a misnomer because it is anything but,” he said. “Look at the minimum wage for some people. It may be $15 an hour or about $31,000 a year. If their insurance deductible is $3,000, that’s about 10% of their gross wages and their out-of-pocket could be $5,500 to $8,000. Then they are functionally uninsured with many of the “off the shelf” ACA plans unless they have subsidies.”

Clay cites a recent survey that found more than half of the respondents said they could not afford a $400 emergency room charge or any other kind of financial emergency. Few could afford a catastrophic event. 

“You have a huge percentage of the population with medical debt.” Clay said. “Better Source Benefits is focused on reducing or eliminating medical debt through employee plan design and solid supply chain management.” BL

 

 

OPTIONS INSTEAD OF AN INCREASE… Claim your 30 minutes with John Clay and learn what solutions your company is eligible for in Q4/2023

 

First Year With A Self-Funded Healthcare Plan: What To Expect, How To Prepare

Recognizing that you are into a Strategic vs Transactional solution means positive change is around the corner.

While self-funding a medical plan is (almost) always a wise financial decision, it does present challenges and new opportunities to direct the course your plan will take.

Read More

How Insurance Companies Hide Profits

Fully insured health insurance companies and HMOs are exceptional at playing Hide and Seek, with profit margins hidden in the premiums. Besides the guaranteed profit margins of the Affordable Care Act (15-20% of premiums) , its new extra charges and taxes, you have to look really hard to find out where the contingency margins are hiding in the premium calculations – especially when you consider that there is very limited transparency in the actual healthcare renewal calculations. 

Ask yourself – did your employees’ good health and low healthcare utilization send a surplus to your corporate bottom line or to the insurance companies’?

So, where are the good profit margin hiding places in the fully insured premiums? 

Let’s take a peek at the ones hiding inside the employer-paid healthcare premiums – For starters, try looking at these little gems:

  • pooling charges, 
  • These are premiums for Stop Loss Insurance that your insurance company buys from its own reserves
  • Industry Loads on the risk factors
  • These are up charges for your type of industry, created by actuaries that work for  the insurance company
  • medical claims trend factors,
  • These are made up numbers that justify the need ofr more revenue, just like any other business plan 
  • demographic load factors, 
  • These are up charges for your employee mix, created by actuaries that work for  the insurance company
  • pharmacy claims trend factors
  • Drugs Companies adjust their pricing twice per year.  They add and they subtract from these depending on how their drug list is performing to their business plan
  • or the capitation trend factors. 
  • This are charges for fixed cost items like mental health, organ transplants and other bundled medical care that rarely are used but always seem to have an increase

Wait! There is more…

Of course, there are more profit margin hiding places in the retention factors, IBNR reserve,(IBNR, we call it “Incurred But Not Really”) some still use terms like 

  • Rate stabilization reserve,
  • More of your money they keep to offset claims 
  • pending claim reserve 
  • More of your money to hedge against something that might happen
  • and the earned interest rate assumptions built into reserves.
  • That earned interest is never not enough to move the needle for your benefit

Don’t limit yourself playing Hide and Seek with your local fully insured health insurance company or HMO, because the game is rigged against you as long as there’s no financial transparency, profits can be hidden, your company’s good claims subsidize bad risks and you have no way of being rewarded for good claims.

Hiding an elephant in the room has never been easier. But I can make sure it’s not hidden in your healthcare plan.

Don’t postpone your free one-on-one session. Summer is the right season to start.

Click here to arrange a one-on-one meeting with John Clay >>