FMMA Arizona Chapter Meeting, Marshall Allen

So I'll just use them on my side and I'll go through the presentation that way. So. And of course, if people have questions, please do again, just put them in the chat or interrupt. I think it'll be a lot more fun and more interesting for everyone if we just make this a conversation as much as we can. But let me. Let me talk here. So a little bit about me.

I got into this as a journalist, and I never actually intended on writing about healthcare. But when I was at the Las Vegas sun newspaper, I was invited to cover the healthcare beat. And the first words out of my mouth were, I can't imagine anything more boring than writing about healthcare. And it's funny, I think a lot of people. So I, you know, I can relate to people who don't want to think about healthcare or employers who don't want to think about healthcare. People think it's so boring and uninteresting. But in reality, it is extremely fascinating and extremely important. And there's big money at stake and there are life or death consequences at stake. And so as soon as I started writing about healthcare from the point of view of the patient, I found that it was riveting to write about and also of utmost moral importance. I've covered healthcare now for about 17 years as a journalist. I was at ProPublica for more than a decade. And I am also an educator. So I'm the founder of Allen Health Academy. Allen Health Academy came out of my work as a journalist, and it came out of my work as a professor of journalism at the City University of New York Graduate School. And it also came out of writing my book. I wrote Never Pay the First Bill. And I saw this need for more health literacy training. And so I took the book, I turned it into a series of health literacy videos that are based on the book called the Never Pay Pathway. And now my goal is to educate and empower employers and working Americans to navigate the health care system and achieve the goal of saving a lot of money on health care while experiencing better health care benefits and better health care. It is possible. It's happening. And that's what my book and my videos really highlight. I also started recently, well, I guess about a year and a half ago. I now work for the federal government, so I work for the Office of the Inspector General for the Department of Health and Human Services. And that's been a delight to work for the government because now I have access to information and I have a lot more ability to make recommendations about things that need to be changed. I'm obviously not here speaking on behalf of the federal government, so this is not why I'm here. And I have to say that every time I speak, just because obviously I'm here to talk about my role as an author and educator. And then before I was in journalism, I spent five years in full time ministry. And I bring that up because.

I think it's my mindset and my view of health care and this issue might be a little different than some. I look at this as a moral and ethical problem. The fact that we have so many players in our healthcare system profiteering off the sickness of patients, really creating business models to exploit that sickness and the work of the clinicians for profit, that's to me, a moral and an ethical issue. In some cases it is a legal issue, but at least it's moral and ethical. And so I really, that that motivates me a lot in terms of my perspective, being a morally minded person, as I'm sure it does for many of you too. And then importantly, I'm also a Coloradan, and I bring that up because I grew up in Colorado. I'm proud to be from Colorado, and I love this recent Supreme Court case in the state of Colorado that really blows up hospital pricing. I don't know if you all followed this case. The patient's name was Lisa French. She was a clerk in Colorado who needed to get a spinal fusion surgery. She went to a hospital and she got a price quote up front, which is pretty admirable that she did that because we all know that most patients don't do that. They told her that after her insurance, it would cost about $1,300 for her surgery. And so she put down $1,000 upfront, she had the procedure, and then weeks later, the hospital contacted her and said, oh, I'm really sorry, but your procedure was not actually in network with, we're not in network with your insurance plan. So therefore, they charged her the full Chargemaster rates. And believe it or not, the Chargemaster rate for her spinal surgery was about $303,000. Now this is a clerk at a shipping company in Denver. She doesn't make $300,000. She does not have 300 grand lying around, just like probably none of us do. And so she couldn't pay her bill. And so at that point, the hospital had the audacity to, to sue her for the, the payment. I think her insurance plan paid about 70,000, so she owed about 229,000. And so they sued her for the 229,000. Well, lo and behold, she couldn't pay that bill either. So she ends up in court with the hospital. Well, the jury made a really important decision, and it ended up being a landmark decision because it was affirmed by the Supreme Court. The jury decided that because the hospital did not give the price up front to the patient. This is what's called an open price contract. And in our Uniform Commercial Code. I'm going to show this to you in just a minute. The Uniform Commercial Code says that if a price is not given for a service up front to a consumer, then it's what's called an open price contract. And that means that the two parties have agreed that a price will be set later. But under the law, under the Uniform Commercial Code, which is the law that governs all consumer transactions in the United States, it's assumed that the price will be a reasonable price and that the price will be set in good faith. Well, $300,000 chargemaster rates are not reasonable or in good faith. So the jury ruled in favor of the defendant and determined that she only had to pay. I think it was about an extra $700, not an extra 229,000 DOL balance bill. So the hospital then, of course, had the audacity to appeal this. The hospital won on appeal. And then this went to the Colorado Supreme Court. And the Colorado Supreme Court just ruled on it. I think it was last May, so almost a year ago. And they ruled in favor of the defendant. And in their opinion. I, in my slides, I have these pulled up. But you can just Google Colorado Supreme Court opinion, Lisa French case, and you can see this, or I could, I could send you an email about it later. But you should read this for yourself because they lay the argument out for everybody right there. And it says when parties have entered into a contract, this is from the Supreme Court opinion for the performance of services. But the contract lacks an express or definitive price. It is a general rule that the court is required to determine the price on the basis of the reasonable value of the services provided.

And I love that term reasonable. They can't just charge whatever they want. And so we've had a practice of hospitals, doctors, others, charging whatever they want without giving a price up front. And then if you Google open price term and UCC or Uniform Commercial Code, you can pull right up the open price term. And what it says is if parties, the parties, if they so intend, can conclude a contract for sale even though the price is not settled. In other words, you can conduct a consumer transaction without setting a price in such a case, the price is a reasonable price at the time of delivery. If nothing is said as to the price which is occurring here in healthcare, and the price to be fixed by the seller or the buyer means a price to be set in good faith. In good faith. What's the definition of good faith? Well, if you look at the Uniform Commercial Code, good faith means honesty, in fact, and the observance of reasonable commercial standards of fair dealing. Again, that word, reasonable, good faith, reasonable. That's what's required under the law when prices are not given up front. And this is a really empowering thing to know. I mean, so the Colorado Supreme Court said the price term of the party's agreement was left open and the trial court properly allowed the jury to determine the reasonable value of Centura's services here. Centura was the hospital chain.

This is game over for unreasonable hospital prices. This legal argument, which is actually the same argument I make in chapter five of my book, which talks about how patients can use small claims court to sue doctors, dentists, hospitals, anybody who is billing them unreasonably, I show how to make that argument in the Uniform Commercial Code. That's in my book in chapter five. It's also in my health literacy video that I made about suing in small claims court. So I'm empowering consumers and patients with this information already, but obviously to have the Colorado Supreme Court make this the legal precedent in the state of Colorado, and that same legal argument applies in Arizona and in every other state. This is hugely empowering to.

Employers and employees, working Americans in every state across our nation, because everybody is being afflicted with these unreasonable prices.

So the hospital price transparency rule, which I'm guessing most of you are familiar with, but this is the rule that the Trump administration put into place by executive order that requires hospitals to post all their discounted negotiated prices on their websites. And so what I like to do is I go from town to town when I talk and when I go visit people, and I like to look up local hospital prices. So I just looked up Mountain View Vista Medical Centers level three ER visit charges. And again, this isn't the charges. This is the discounted price that's actually paid by different health plans for a Level 3 ER visit at Mountain Vista. And this is just pulling off their website so you could, you could look this up yourself. But United Healthcare's negotiated price for a level three ER visit is $795. The Cigna price is $890. The Blue Cross Blue Shield of Arizona price is $324. So Blue Cross patients are somehow getting a much better price than United or Cigna.

The Medicare price is $246 and.

Believe it or not, the self pay price is $292. So if you have the self pay price, if you walk in as a cash paying patient to the emergency room at Mountain Vista and you have a Level 3 ER visit, your cash price is much, much lower than any of the big insurance companies that people depend on to get them the best negotiated rates. How is that? I mean, I thought insurance companies are supposed to be getting us all the best deal, right? Aren't they leveraging the market power, consolidating all their members, negotiating great deals for us? No, they're not. And this is what's being shown now with this price transparency. And that's the power of price transparency. Now we're seeing the unreasonable nature of this hospital pricing. So every patient who's insured by United, Cigna or Blue Cross Blue Shield of Arizona who gets that service at Mountain Vista has been billed an unreasonable price. Their health plan has been billed an unreasonable price. And if they weren't given that price up front, which I can almost guarantee you they weren't, then under the Uniform Commercial Code, that would be a price that is unlawful and they would have, they should take action there to push back against these prices. This is how it's done. So let's look at Arizona General Hospital in Mesa. I mean, I'm not cherry picking hospitals, by the way. I mean, I could do this in every city. I just picked two hospitals at random that had files online. So. And I'm also not cherry picking services. You can see this price variation in every service at every hospital around the country. It is really this absurd. So level three ER visit prices at Arizona General Hospital in Mesa. UnitedHealthcare, 1564 dollars. So right there, Arizona General, a United patient pays 1,564. It's half that at Mountain Vista. Cigna patients, 787 dollars. Again, Cigna's paying half as much as United Healthcare. Patient Humana's at $1765. They're the highest of all. And Aetna's at $1678. So this is not reasonable in terms of the pricing here. The cash pay patient is at $1,287, which is lower than most of the big insurance companies, although it's not as low as the Cigna price. And the Medicare price is $237. So again, if we're Trying to figure out what's a reasonable price for a patient to pay. How is it reasonable for a Medicare patient to pay $237 for that ER visit and a Humana patient to be paying $1,765? And as we know, so many patients now are on high deductible health plans that they're paying that entire amount out of pocket. And if they're not paying it, their plan is paying it, which is also coming out of their compensation. So one way or another, the workers and the employers are paying these unreasonable prices. And this is just the status quo. This is how it's always been. This has become accepted. It's normalized deviance. It's taking what's wrong and saying it's become right, and it's not right. And so we have strong arguments now to overcome this type of unreasonable healthcare pricing. And that's what I've been doing with my book and with my videos. I'm trying to educate employers and employees and working Americans, maybe who are uninsured or getting their insurance through a health sharing plan, or maybe they're uninsured, or maybe they're getting it through a marketplace plan. I'm trying to show people, hey, you know what, if you can just learn a little bit of financial health literacy, you will save yourself. You could save yourself hundreds or even thousands of dollars per healthcare encounter. Then imagine if this education could be multiplied across an entire employer sponsored health plan. Well, then you're exponentially multiplying the savings every time a patient goes to the doctor or to the hospital. That's really the campaign I'm on. Now. This is of utmost importance because we're at a point right now where the pain is so great that it's motivating a lot of change. And we see that pain on a lot of levels. I mean, Doctor, who was it? Dr. McKenna here is talking about a desire to jump to direct primary care. I mean, we're seeing lots of doctors who are experiencing moral injury because of the nonsensical nature of our health care system that's so driven by the financial side of the system that doctors and nurses are abandoning the system. But they're looking for something different. We're seeing more and more direct contracting with ambulatory surgical centers and labs and hospitals. We're seeing more direct primary care. This movement is really growing. We're also seeing more patients who are wanting to learn. They now say that about 100 million Americans has medical debt and about 1 in 5 has medical debt in Collections patients are more willing than ever to be inconvenienced to save hundreds or thousands of dollars. Again, that in the past, employers were very afraid they would use this idea of friction to the employees as an excuse not to do anything. But now we're seeing more and more patients being ready to learn and wanting to take action and wanting their employers to take action.

Policymakers are also providing us with opportunities. So I mentioned the price transparency final rule, the hospital price transparency final rule. We also recently have the transparency and coverage final rule. This is for health plans that are now required. Back in 2022, they started to be required to publish all of their negotiated prices. This is a much bigger data dump than the hospitals. This is for all their services, labs, ambulatory, surgical center, outpatient clinics and hospitals. Now this data is becoming available and you have data scientists right now working on crunching these files, making them easier to use. So the movement is growing. There is a lot of action in this space. The Consolidated Appropriations act is another really important piece of legislation. One of the provisions in that law says that employers now have access to data. So the CIA banned agreements that insurance companies made with employers that would restrict. I'm looking at it right here. I have it pulled up, but obviously you can't see it. That would restrict providing provider specific cost or quality of care information to the plan sponsor or the participants or the beneficiaries. And so now using the Consolidated Appropriations act, we have employers leveraging that, going to their carriers and saying, I have a right to my data under the law. I need that data, especially now, because they are the fiduciaries of their, of their plans. And there's becoming much more attention and focus through the Department of Labor on employers being fiduciaries.

The Consolidated Appropriations act also had some really important provisions about broker compensation transparency. This actually came about because of a story that I wrote about the high cost of commissions and hidden bonuses that are paid via the health plans to health insurance brokers. And you all probably know how this works. I mean, brokers can be making income previously that would be hidden to the employer from the tpa, the pbm, all the different vendors and companies attached to a health plan could be feeding a commission and hidden bonuses to those brokers. Direct and indirect compensation, that could add up to a lot of money. And also it would really lock the broker in to doing what the carrier or what the PBM wanted. It would create a conflict of interest. And what's happened now is you're seeing more brokers because now through The Consolidated Appropriations Act. It's required for brokers to disclose all direct and indirect compensation to the employer. And the employer has a fiduciary responsibility to know that information and make sure that they're not being taken advantage of and that their plan is not being exploited by these unreasonable costs. So we're seeing a big change now with brokers. Brokers are saying, oh, I need to now justify the cost that I'm bringing in and maybe I need to detach from the industry alliance and start aligning myself with my employer. Who are they really serving? They need to make sure and show that employer that they're serving them. So we're seeing now a movement in getting paid directly by employers, fee based advisors instead of commission based brokers. So now these advisors who really are worth their weight in gold to the employers, are being paid directly by the employers, which aligns their incentives. Now they can show their value to the plan by doing things that save the plan money. They can bring in a data analytics vendor. They can look at claims and make sure that they're not being over overpaying for those claims. They can enter into direct contracting relationships with providers or center of excellence relationships. They can enter into direct primary care relationships, and they can partner with transparent PBMs. This is happening right now. Carl Schuessler, I know, is on the line here. This is, this is something that Carl does and he's an expert at. And there are other brokers and advisors in this movement and more joining them. And so I think that's what's important to know. This is, this is happening right now. I see a question here from Sean. How do we validate all broker commissions and bonuses disclosed or actual? So my understanding, Sean, is that this would be the responsibility of the employer now to do that, to check on those things. But someone else on the call might know even better than I do. Carl, do you have an answer to that question?

Yeah. Can you hear me?

We can, yeah.

Okay. All right. I'm in the car. So I didn't want to show my. My ugly face to everybody.

The broke. What we had to do as advisors, Marshall, is, you know, come what I guess was a December 27 last year, by that time we had to have a document. I'm glad to share what we do with our clients. If I was back at my home, I could pull it up. But we did, we did put it together and get it, got it to all our clients, stated what our compensation was. The Marshall, I'll tell you it was. It's a step in the right direction. But it's like percentages of stuff. So if you're getting, you know, any commissions from like some of the non medical benefits, dental, vision disability, those type things, you just put your percentage of commission on there. But it doesn't say, well, what's the premium? It doesn't ask you. Well, they're paying a million dollars. Yeah, and I thought that was kind of hokey myself. But for me to put down what I could put what I made last year on that plan. But you put in your Marshall, your PM that you charged for the plan, you know, to, to manage their medical plan, you could see that. And then the employer could figure out, Well, I got 500 employees. So we pay this person X. Yeah, but we did put.

So it's a good step in the right direction. And then is there any way to validate it and check it?

I don't know how they would do.

Looks like you're breaking up.

Oh, I'm sorry. Can you hear me now?

Yeah, we can now. Go ahead.

Yeah, I don't know how you would do that, Marshall. And at this point to be able to really do that, I don't know. I mean, I think it's, it's the honor system, I guess, because I don't know how they could ever figure that out unless they went to the TPA and said, hey, what did you pay this person? But normally on the, on the premium billing invoices, Marshall, from the tpas, it has the advisor's fee listed there when the, when the employer gets it.

Right.

So but from the rest of it, you know, the insurance companies, if you use them for the dental and division, they do send that to the employer, normally 5,500 fees. Yeah. So they get that. But if somebody's getting a buck of scripts, you know, like you and I've seen before. Yeah. Every time somebody does a script out of that ain't going to show up anywhere. PBMs aren't doing that.

So it's a, it's a step in the right direction, but maybe still limited. It is, but it, but it is a, but it is a big step in the right direction and it creates accountability and it also is, is pushing brokers to move what I think is in the right direction.

Marshall. Guys, go ahead.

Matt, real quick. Yeah, I think what's interesting too is that, Marshall, what's happening is all.

Lawyers having to pay us.

No, but you're breaking up on us, Carl.

I'm sorry, hold on, let me see. Is that better?

Go ahead, say it Again.

Yeah, the employee. Yeah. What's happening, Marshall, is with these independent third party administrators that are providing this software to be able to, you know, get prices and price shop for the plan. They're providing it, but they're paying for it. And now they're passing that on to the plan sponsor, the employer. So where the law is good is costing everybody more money, too. I just wanted everybody to know that. Yeah, no, TPA is going to give that away for free. And if you're fully insured with Blue or United or any other Cartel carrier, they're putting that all in your premium. So there is no free lunch.

Yeah.

And I just know we're getting there. We're getting there. You know, to your. Yeah, I'll shut up.

All of.

All of these things are steps in the right direction. Sometimes they're baby steps, sometimes they're not. They don't have as many teeth to them. Like for instance, the, the hospital price transparency final rule has a very low penalty for hospitals that are not compliant. And so in the beginning, it's been now two years since hospitals have been required to post prices and they are inching toward compliance. But when I say inching, they're moving slowly. But I will say that pressure is being applied to them. And you're seeing states pass laws that require it. Colorado passed a law that said, I think the law was no hospital is allowed to send a debt to collections if they are not posting their prices. If they're not in compliance with the rules, we're seeing states pass laws. Texas also has a price transparency law. We're also seeing.

Enforcement by Medicare. So Medicare has penalized two hospitals, which is not very many, obviously, but they've also sent letters to many, many more. The OIG is doing an audit about compliance with that final rule. So we are seeing more and more compliance. I think the last report I saw from the Patient Right Advocate Organization was that about 50% of hospitals are now compliant. And if you follow Leon Wisniewski from Health Cost Labs, which I'd recommend you follow him because he's been gathering all this data, processing it, making it user friendly. And I think he is seeing, if you look at the map he has on his site, we're seeing a lot more compliance with it too. So it's taken two years to get maybe halfway there, but we are moving in that direction and I believe the pace is accelerating. So here's how, here's what I'm trying to do personally. So I wrote the book and I had a health insurance advisor Ask me to create videos based on the book. So I created a series of videos called the Never Pay Pathway that just take the information in the book and communicate it in about 16, maybe. Each video is about five minutes each. Those basically are an engaging way to educate consumers, employees, employers, people who wouldn't necessarily read a book. It brings the knowledge to scale in a way that's much more engaging. What it's been fun is seeing different patients take the things in the book and, and apply them. I think one of my favorite two words in the title and subtitle are Never pay the first bill and other ways to fight the healthcare system. And win. And win are the two most important words. Because what we really want is winning. We need employers and employees, working Americans to fight back and win. We've done plenty of work to identify the problems and I've done that for years as an investigative journalist and we still need to do that. But what we also need to do now is highlight the successes so that it can be normalized that employers think differently about the way they design their health benefit plan and so that employees and other working Americans who are getting their health benefits independently engage with their health benefits. And so I want to share a few victory stories with you about how everyday people have put these tactics into action.

One of them I love is my nephew. My nephew Josh Stone is a building contractor. He flips a lot of homes and does a lot of management of properties. He was replacing a window one day when he sliced his thumb. He ended up having to get 14 stitches. So it was a big slice in his thumb. Josh is a young guy, he's maybe in his low 30s or something, maybe 32 years old. And Josh didn't know until he read my book that you should stay away from the emergency room as much as you can. And so this is basic stuff, but most people do not realize that the emergency room is not the place you should go to get stitches on your thumb. So Josh, because he had read my book, went to an urgent care and he asked for the price up front. He got the price up front, he got his thumb stitched up. And then when it came time to pay his bill, he did the other thing that I recommend that everybody do. He asked for a discount. He's a cash paying patient, he's on a health sharing plan. And so he got the price and then he asked for a better price. We all know these prices are made up to begin with. So every patient in every scenario should be asking for a discount. And I love when People say to me, but what about, you know, the insurance company has, has set a price, a contracted price with that hospital or with that doctor or with whoever. I don't care about the agreement that the hospital made with some insurance company. That's, this is a three party contract or maybe a four party contract between the employer, the patient or the worker, the hospital and the insurance company. Okay? Just because the hospital and the insurance company say a price needs to be 1500 dollars doesn't mean that I, as the patient can't say, you don't make me pay something I didn't agree to pay. Okay, so there's a lot of these supposed rules that have been set that we've all been following that are nonsensical rules that are designed to exploit us. I see Will has a question here. Back to the idea of reasonable. Can't this just mean Medicare rate as determined by the federal government? Does the government definition not count as reasonable to the lawyers? Yeah, that's a great point, Will. I agree with you. That's a great point. And that's, that's the basic argument behind reference based pricing. Right? Use Medicare as a reference based price and pay some percentage over Medicare, but reasonably under the Uniform Commercial Code. If they're accepting a Medicare price, then why in the world should a working American pay them two times more, five times more than Medicare, 10 times more than Medicare? That is unreasonable and it's price discrimination against working Americans. So yeah, well, I agree with you 100% with that, with that argument. So that's Josh's story, and I love that story because he put all the steps into practice and he got a big discount and he paid it on the spot. I love this story too of Leslie Donovan. This is one of my favorites because I love the idea of David beating Goliath. And that's what I talk about in my book and videos, how the little guy can use some strategy and some principles and some savvy to beat the big guy. And we're seeing that happen all the time. Now. Leslie Donovan took on one of the biggest, biggest Goliaths of them all, Sutter Health, which you all may know is a hospital system in Northern California that is notorious for its price gouging. They've had many multiple government settlements where they've had to repay, I believe, hundreds of millions of dollars. Don't quote me on that, but I know it was some massive settlements. And Leslie Donovan went there for an ultrasound and she was charged $1,300 for the ultrasound. Well, she followed the Steps that I lay out in my book. Again, she didn't get a price up front, but in my book and videos I actually called my videos the Never pay pathway. Because what I've done is I've shown the pathway that people need to take when they're understanding and then maybe contesting a medical bill. The first step, you have to get an itemized medical bill with the billing codes. Then you check that itemized bill and make sure that all the charges on that bill were actually services that the patient received. So that's the first step. Make sure that you're only being charged for things that actually happened. Then if you have those billing codes.

You can look up a fair price@fairhealthconsumer.org or Healthcare Blue Book and you can see now or the hospital websites. If you went to a hospital and you can see now what other payers are paying, what other discounted negotiated rates are, and you can see if your prices are unreasonable or not, then you can also get your medical records. And when you get your medical records that then can show like, let's say they often upcode with like a level 5 ER visit. That's very common to get upcoded. But if you get your medical records and it shows it was a non complicated simple case where there was no in depth examination even provided well, then you have legal evidence that shows that this was not a complicated case. That's leverage to negotiate these bills. So in Leslie's case, she got the itemized bill, looked up and priced the billing codes, she got her medical records, she checked the prices and then she saw she was being overcharged. And when they did not respond to her, she sued them in small claims court for the difference between what she was being billed and what a reasonable price is. And I'm really happy to say that like other patients who I've shown how to do this, she got a prompt call from the hospital attorney. And in this case the hospital attorney waived the entire bill. She figured she should have paid about $300, but they waived the entire bill as long as she would drop that case. Because think of the hassle you're creating for the hospital. If you sue them in small claims court, you are requiring them probably to hire an attorney or have their general counsel or some attorney they have on staff look at it. That costs them hundreds of dollars an hour for a case that might be only worth about $1300. You're also creating a legal precedent and legal accountability for them, which is another thing they don't want. And the small claims limits are actually quite high in a lot of different states. I mean, In Colorado, it's 7,500. Here in Texas, where I live now, it's $20,000. In Tennessee, it's $25,000. So some states, I think the lowest state is around 3,500, but it's enough to cover a lot of these bills. Leslie, again, this is just a mom of five who wanted to stand up for herself. This is empowering to patients. She stood up for herself and she beat back the bully of the health care system that was overcharging her. I love this story about another patient named Jenny Sisson. Jenny's a mom in Texas, rural Texas. Her daughter went to the hospital for an appendix inflammation of her appendix. Had to get the appendix removed. It was a rural facility. They build her at a level 5er visit for that visit. Well, a level 5er visit is only supposed to be used for cases that are like a complex car accident. Patient comes in, multiple trauma, a patient, overdoses, is near death, needs to be resuscitated. Level 5 is for extremely complex cases where they also perform an extensive examination and an extensive medical history on the patient. They can't just charge level five whenever they want. That's not right. That's either an error or it's fraud. And so, Leslie, excuse me. Jenny again, read my book, followed the path that I lay out in the book. And she just, all she did was call the billing department and say, hey, this didn't really seem like a level five visit to me. It doesn't seem like it was that complicated. Well, in this case, they were charging her $465, and they had already been paid $3,700 by her health plan. And so in this case, they waived the entire her share of the bill. They kept the 3,700, of course. And what really needs to happen is employer sponsored plans need to be analyzing these claims. And the whole thing should have been reprocessed. In this case, she was able to save $465, which is great, with a three minute phone call. Again, this isn't always very difficult. Sometimes it's super easy to make these calls and push back on these things if you know how to handle it. Then I love this. Jenny doubled down. So she went, her daughter went to another hospital where she had her appendix removed. And when Jenny got the bill, she followed the steps I lay out in the book and that I lay out in my videos. I have a whole video on how to apply for financial assistance and Even I refer people to a charity called $4, which will apply for hospital financial assistance for you for free. So every employer sponsored health plan needs to let their people know that they probably qualify for hospital financial assistance if they're say, middle income or below. So Jenny applied for financial assistance on her own, which it is easy enough to do on your own. They forgave $4,300 of that bill for her. And so she ended up paying $755 was her share. So again she says, I paid $20 for a book and I made back all this money. And so that's really my vision. I mean, I was talking to the head of a TPA recently about hospital financial assistance policies. And my vision is to make these videos a part of every employer sponsored health plan so that employees, each employee has a subscription to the videos for a year. They can then watch the whole curriculum and get this base level of understanding about how to protect themselves financially and how protect their health plan, which is their compensation. They should be protecting it from these predatory practices and how to take advantage of something like a hospital financial assistance policy. Imagine if every patient who qualified called up $4 and worked with their advocates and applied for financial assistance. We would be seeing exponentially more hospital bills forgiven at a massive savings to the employees and the employer sponsored health plan or the health sharing plan or whatever plan people are being covered by. So I love that story though of Jenny because she won twice. Sometimes it's a matter of protecting people from unnecessary care. So the greatest victory is the battle that you didn't even need to fight. That's actually Sun Tzu says that in the Art of War. I'm paraphrasing, but I was referred to a guy named Jeff who was told he needed a spinal fusion surgery. And so he told me he needed me to help him find the right doctor for the spinal fusion. And he had a lot of pain in his neck. And I said, well, Jeff, look, just so you know, a lot of these back surgeries are unnecessary, so just be real cautious when you do this. But I did refer him to some doctors. I did some background research on some doctors. I helped him find some doctors. He went to the first doctor and that surgeon told him, jeff, if we don't do surgery immediately, you are going to be possibly paralyzed. If you so much as go golfing on Saturday, you could end up in a wheelchair. I want to book this for you right now. This is an emergency. This guy tried to press him to book a surgery immediately. He went and got a Second opinion, the next surgeon said, we definitely need to operate. It's not, you know, it's quite an emergency, but we definitely need to operate. Jeff was skeptical. Instead of going to a surgeon, Tim Spooner, I'm sure you know this very well. Jeff went to physical therapy. He only went to about five physical therapy appointments. He learned some stretches, he learned some exercises. He started doing those at home. He also changed his taekwondo training. Jeff is a 4th degree Taekwondo black belt. He's about 50 years old and he was training like he was a 20 year old instead of he was a 50 year old. Well, that might cause some neck pain. So he reduced the intensity of his training. Lo and behold, his back and neck pain went away. And now Jeff, he's become a friend of mine because he was a friend of a friend here in Texas. Now I'll see him every now and then when our other friend or mutual friend will have a party. And I still check in with him. It's now been about three years. And I'll be like, hey, Jeff, how's your neck feeling? He's like, still good, I'm still good. And he just shakes his head now thinking that he, if he would have followed the advice of those doctors, he would have had that had his spine fused at a great cost to him and his health plan and also at great risk of complications. And it would have caused limitation to him going forward. And he still trains in taekwondo. So again, my vision here is to change the way employees and employers and all working Americans think about their engagement with the healthcare system. I know, I mean, I was like them. I felt bored when I first thought about it too. But I really want people to be, instead of being apathetic about it or feeling paralyzed by it, they need to be engaged and alert instead of being ignorant and vulnerable. Because hospitals won't tell you about their financial assistance policies, I want people to be informed so now they can apply on their own or they can go to $4. And instead of being intimidated and bullied, I want them to feel empowered. And that's one of the greatest satisfactions of doing this. Health literacy training and this empowerment of the consumer so that we can take these free market principles and we can expand them so that we can all save a lot of money on our healthcare. If we look at our spending on health care, about 4 trillion a year, about 25% of that is considered to be waste. As I'm sure a lot of you know, it's waste where high prices that are unjustified and unreasonable. It's over treatment, like the kind of surgeries that my friend Jeff almost got. It's fraud. Fraud is rampant in our healthcare system. Estimates are that about 10% of everything spent on health care is fraudulent. And it's especially bad in the employer sponsored health plan space. If you're not looking at your claims and don't have someone looking at your claims, you are having massive amounts of money go out the door. I can guarantee it. And then administrative complexity is costing us hundreds of billions of dollars a year in wasted healthcare spending. So this is something that works, that we need to build this movement for employers and for working Americans to become educated and informed and empowered. And it's my pleasure to talk to you about it today. So we can, I can answer any questions. I'm sure I probably missed some in the chat. And then of course, if anybody just wants to throw whatever question at me, we can, we can talk about anything you'd like to talk about. Thank you.

I'm skimming for questions, but does anybody see any that I didn't ask or have any that you'd like to ask? I see Adelita Jamis says, true paying cash is interestingly cheaper for the patient. I recommend patients to pay routine blood test cash, blood tests by cash instead. Definitely. I've seen that myself. So I was recommended to get a blood test. This is when I was at ProPublica, I put this in the book and I called the lab and I said, hey, I'm covered by United Healthcare. How much is it going to be for my blood test? I think they said it would be about again, it's in the book. So I don't remember now, it's been some time, but I think they said it'd be about $80. And I said, well, how much will it be if I pay cash? And they were like $18. And I said what? Does that make any sense? And the guy was like, no, it doesn't make any sense. It's just insurance companies. You end up chart, you end up paying more A lot of times.

Marshall.

We talked a couple of times about laws that might help improve transparency and improve.

The system. We've also seen laws be put in effect like the transparency laws that are not being followed very well. And so I'm wondering, do you have, do you have hope that laws will actually make a difference? And if so, what laws would those be? How would they be enforced? And, and if not laws, you know, what, what things will help to shift this whole system?

I mean, I think some of these laws that have been put into place. You can maybe say they don't go far enough or they don't have great enough enforcement, but the hospital price transparency final rule is a massive, massive breakthrough for free market healthcare in this country and for consumer empowerment and for fairness. And so it's difficult to use right now. I mean, you have to know how to log on to a hospital website, bring down an Excel spreadsheet and look at an Excel spreadsheet. So it's moderately complicated. A lot of people wouldn't be able to do that, but a lot of people can do that. And I tell you who can do it. The advisors, the brokers, the employers, they can do that. They should be doing that. Why isn't, I mean, if I were an employer or an advisor, I would be subscribing to Leanne Woznowski's feed of data and looking at that and saying, okay, why am I with United or Cigna or Aetna or Humana or one of these other companies if they're not even getting me the best deal on healthcare? That makes no sense. And again, you have to look at the common services and everything else. I know those prices balance out in different ways. But obviously the system we have right now is absurd and it's not going the direction we want it to go. So people cannot continue to do the same things and be considered responsible fiduciaries of their plans, in my opinion. So I think the hospital price transparency final rule, I think the transparency for health plan data, that's huge. Again, it takes some time for the experts to manage all this data, to put it into a usable format. It takes changes in consumer behavior. It takes changes in employer behavior. That's something that I'm working on. That's something many of you are working on. That's what we're all working on. So it takes time to bring about these changes. But it is powerful information. And I'm telling you, when I, when patients I've helped now personally, about a dozen patients sue in small claims court, they've all won easily. This isn't even an argument. There's no legal ground for the industry to stand on with these practices. So I think that these laws are effective. The no Surprises Act, I think it's limited, but it's effective. Here's one way I think it's effective. I have helped patients who get balance bills call the no Surprises act hotline. There's actually a hotline at the Department of Health and Human Services. There is a federal government employee or contractor answering the Phone. Hello, surprise bill hotline. It's hilarious. It's amazing. So now that you have that hotline and you have this law in place, if you get a balance bill or a surprise bill since 2022, which is when that law went into effect.

You can file complaints now with the federal government about that. Does any hospital want complaints filed with the federal government where the federal there might be a risk of the federal government coming in and asking them questions about their billing practices? No, they do not. And so I have a template on my newsletter website. I also I want to point you all to my newsletter. That's@marshallallen.substack.com I'll put it in the chat here. That's a free health literacy newsletter where I write about these tactics and I share these victory stories. But in this case, I helped a patient with this substack.com I'm just giving you that link.

I helped a patient with that template to send to the hospital she sent it to again. I told her, don't just send it to the billing department. Send it to the general counsel's office. Send it to the CEO's office. Find the board members, send it to them, tell them you're in violation of the no Surprises Act. I called the no Surprise act hotline, which she did after I did. And they told me that this would be the kind of case I could file a complaint about. You need to come to a reasonable agreement with my insurer or I will file a complaint with the federal government and they'll investigate you for a violation of this law. She got a call the next day from the head of the billing department, apologizing to her, saying, I don't know who you reached out to, but it worked. And they ended up dropping that bill by a great amount, even lower than they should have for her. So there is a lot of leverage that we have. I'm putting, I'm going to put the link for the videos in here.

It's at allenhealthacademy.com for to check out the videos too.

Other questions? Oh, Sean Strash, When I we coordinate surgery bundles, we direct the patient to leave their insurance card at home for the very reason the insurance price are typically higher than cash pay. Yeah, that's that, that's a great suggestion because unfortunately the hospitals too will also lie to the patients and tell them that, oh, if you have insurance, you're not allowed to pay cash. That's not true at all. But you hear it all the time. The problem here is that the employers and the patients have been believing a massive facade that the healthcare industry has put up. And the facade is that they actually know what they're talking about and that they care about the best interests of patients. They don't often know what they're talking about and often the incentives are not aligned with what's best for patients. And so it does require the consumer and the employer, the real payers, to be a little more educated. You can't be trusting and naive of somebody who's preying on you. Okay, like let's wake up, folks. Snap to attention. Like, get it in gear. Let's wake up because there are all these resources available through advisors, through vendors to solve these problems for you. So stop doing the same old, same old. Right? That's what we need. That's what we need employers to do.

This is Will again. Hi Marshall, thanks for coming and doing this. I have a question regarding.

Your different websites, the substack and your.

Allen Health Academy. Are you by any chance pointing people who use those sites to other resources like Direct Primary Cares or Health Rosetta Brokers or things, you know, resources of that nature. So that because you're in a powerful position in the marketplace to be an educator, obviously. And a lot of these employers, they, if they don't understand self funding or even if they do understand self funding, a lot of this stuff may be completely new to them and they may not know where to turn.

Yeah. So in my book, I have three chapters in the book that are devoted to employers and I talk a lot about Health Rosetta in the book. And I think I might mention the next gen folks in the book too, but I know I mentioned Health Rosetta and I mentioned a few different vendors. I try and be careful about who I point people to specifically because.

My goal isn't to promote anybody. I'm really not trying to promote anybody. But what I'm trying to do is show that these solutions do exist. And I don't, I don't want to promote anybody because honestly I'm not doing the checking and the verification to actually see how people operate in the, in the marketplace. But I just tell people like the first thing employers need to do is go to an advisor who is independent and willing to be paid directly by them instead of somebody who's being paid just through the industry commissions and bonuses because that advisor will maybe open their eyes to things that they haven't seen before. And so I definitely think like a Health Rosetta type, that's a great way to start or a next Gen type of an advisor who is really much more independent. And then I do talk about things like direct primary care and other things like that with my videos. The health literacy videos are designed for the worker level, like the employees. And so I don't go into things like talking to brokers or direct primary care in the videos because those are more geared for not planned design, but more engaging with the healthcare system.

Can you give us an example or a scenario where you mentioned that employees across a health plan might be able to lower both their own out of pocket costs and the cost to the plan? Can you just give us, you know, example scenarios of how that would actually work, how the plan and the employee would save money because of, you know, better consumerism and purchasing healthcare?

Yeah, so I love. This is a new thing. So this has not been rolled out widely to lots of health plans. So right now I'm in conversation with a lot of people who are interested. But I, but what I want to be very clear about, because I want to be very transparent. I cannot say that individuals saving money leads to. And I can. You can guarantee that it will lead to lower costs for the health plan? I believe it will. And my goal is once I roll it out, to start testing that and start researching it with some employers who want to do those kinds of tests because I think it will have an impact on claims. But let me give you, for instance, I'm talking to a school district right now that's interested in rolling out the videos. And this school district already has a pretty progressive plan design where they reward employees for identifying errors in their medical bills. And they reward them with cost sharing. If they go to like a center of excellence, direct contracted relationship, let's say for a knee replacement or something like that. Well, so my videos actually show employees how to analyze a medical bill. I show, I break it down into four or five different videos. How to get the itemized bill, how to check it for errors, how to price it, how to look up the medical codes. It's easy to do this stuff. It's really not hard. It's just google or fairhealthconsumer.org, it's not difficult. So now an employee under this person's health plan is incentivized. They're deputized to go find errors in their medical bills. And there's no one better to find those errors than the patient themselves. They know the services they received. They know the complexity of the case. An insurance company doesn't know that stuff. A TPA doesn't know that stuff when they're processing and just auto paying these claims. So now you're deputizing your employees to do this. You're rewarding them with a share of the savings. I mean, for some of these hourly workers, they could make more than they make in a month if they find an error in their medical bill. So this is really incentivizing them in a beautiful way to ferret out the fraud, to ferret out the overpayments, to ferret out, ferret out the unreasonable payments, and then rewarding them for doing that.

They also reward people for going to direct, like a, either a direct contracting relationship for a surgery. Well, I have a whole video about the unjustified price variation in health care. Again, I showed it with these Arizona hospitals with the R bills. But we all know that when you go to get a drug or when you go to get a service, a lab test, an imaging test, there is massive price variation. Well, your basic employee doesn't know that because no one would expect the system to be that unethical and backwards. Right. No one would think that if you went to a hospital for an MRI, the cost could be $3,000, and if you went to an independent imaging center, it might be $300. That's so absurd, it's hard to believe it's true. And yet that's the case in every city around the country in the United States. So I have a video about that. So imagine now employees realize, oh, I can get the same mri, the same CT scan, the same knee replacement, the same colonoscopy, and I can save exponentially more by going to a reasonable place where the price is better. So I think it would be ideally paired with a. Rather than make the employee search all this out, there are some advisors who now have nurse navigators built into their health plan. Now, you incentivize the employee, you waive the cost sharing or even pay them a bonus if they go to the center of excellence for their knee replacement. You're then saving tens of thousands of dollars for the health plan while waiving the cost sharing for the employee and rewarding the employee with even a bonus check. That's happening right now in the most progressive health plans. I think the key, though, I think is to really optimize these things. I really think that the employee needs to be educated and understand that this needs to be a partnership between them and their employer to protect their compensation. I think sometimes employees have this misunderstanding that, oh, well, it's my employer paying the bill, or we have rich benefits My employer pays everything. And so therefore, when they meet their deductible, they just kind of shrug their shoulders and go, I don't really care what happens now. It's a free for all. I don't care where I go. I'm just going to spend money willy nilly in health care because the employer is paying for it. Well, one of the first things that I explain in my videos and in my book is that this is 100% employee compensation. And there's no magic money tree that provides this money. The employer is funding it all. And so if the employer is funding and overspending and wasting money on these high health care costs because of things that can be prevented, like these unreasonable hospital costs or other types of wasteful spending, well then that employer has less money left over the next year to give people pay raises. I mean, it has a real effect. Deductibles go up, premiums go up, benefits get reduced. Those are the tough calls the employers need to make because the money's being wasted. And so employees need to get it. They'd be like, oh, the system is designed to rip me off and take my compensation and I need to partner with my employer to protect it. That's a big step. And then if the employer one ups it and puts these more progressive plans into place, the kind of stuff that Carl is doing and that others are doing, well, then you're really optimizing things. And that employee knows, oh, this is why we do this. They need to know the why behind these things so that they increase their utilization of these nurse navigators and other types of benefits that really help them and save them the plan money.

Well, thank you so much, Marshall. That is. Oh, we have, we have one more question for you.

Here's Michelle.

All right. Hi, Michelle. Hi.

Nice to meet you. I'm the director of HR here at Spooner.

I just emailed you. I'm so sorry I didn't get back to you. By the way, I just found your email tonight when I was looking at Tim's name. So anyway, let's talk after this because I, I do have some ideas for you.

That sounds wonderful. And this is actually from one of the attorneys at one of the hospitals. This is going back to Willa talked about and you talked about when you looked up Mountain Vista and the other one, and correct me if I misunderstood, but you're saying that reasonable could easily be described as what Medicare would be correct?

Well, in my opinion, yes. I think the strong argument can be made there. Yeah.

So we, we, of course, feel the same too. And.

This attorney, in their response to our saying, you know, hey, we're not going to pay, that we're going to pay with the plan pays, they cited two different court cases.

First was Leflo v. United Health Care of Utah. And it was that.

How reimbursement rate is determined, the determination that the allowed amount is reasonable customary is not substantiated because RTPA said these are what we are saying is reasonable and whatever. And she said that it's not that it's under the Affordable Care act usual and customary charges should be reasonable. Otherwise it would defeat the purpose of protections in the statute if a plan or issuer paid an unreasonably low amount to a provider. Sorry, this is probably hard to decipher as I'm reading it to you. And then the last thing that they wrote was, lastly, the courts have found Medicare allowances not, quote, unquote, reasonable. Baker County Medical Services versus Aetna. In determining the fair market value of the services, it is appropriate to consider the amounts billed and the amounts accepted by providers. With one exception, rates for Medicare and Medicaid are set by government agencies and not not be said to be, quote, arm's length. The appropriate rate for the reason customary would be the amount.

Provides to other contractor providers in the area or total billed charges. So they're basically saying, no, you can't use Medicare as a, as the benchmark.

Well, so that's, this is where the fight is going to take place right now. I would have to know what the service was, what they're asking for their price, because again, hospitals will all say that Medicare isn't enough for them to get by on, which I do not believe to be true at all. But that's the argument that they make. And so paying flat Medicare, I'm sure they would push back on that. But then you say, well, then what is reasonable? 150% of Medicare, 130%, 180%, because what they've been typically charging is between 200 and 500 and even 1,000% of Medicare.

So the question is, what was the service? What are the prices like at their hospital and others.

And other facilities? And then what are they asking for, you know, how much, how much are they asking? So that's the kind of stuff that, but let's talk, and I'd love to hear more about that particular case, but in some cases.

The employers are going to have to fight it out and be willing to test this in court. And that's what hasn't really happened yet. But you're seeing these tensions rise, right? You're seeing these cases where the employers are going, no, no, no, no, no. You can't just do that. And of course, I guarantee you they didn't give that price upfront. So it's all this debate about what's a reasonable price.

Right. And we did the, you know, the plan paid what we pay. So the 140, 150. And now this is. All the rest of this is balance bill. And the balance bill is 200,000 or something.

Yeah, yeah. And for what service was it.

Pediatric cancer?

Okay. And then what did you figure? Is there a Medicare price on that or not for pediatric cancer? Maybe not.

It ranged all over because I pulled. We got the itemized bill and I went through that in detail. And their variability, even in their own charges, was significant from, you know, and I did it against Fair Market. And, you know, some of them were, you know, 600%, some of them were a thousand percent, some of them were, you know, 300%, was. It is amazing, the discrepancy in just the very few that I looked at.

Wow. Yeah. So that's complicated. I mean, yeah, you need to break down that whole bill.

And see and then price out each of the codes. But that's. That's a. That's a big task. I mean, that's the kind of thing. So what I do now, like, with my Substack newsletter, it's a free newsletter, but I encourage people to donate if they want to. And I take that money and I use it to hire patient advocates for patients who are caught up in those kinds of complicated circumstances. But I would recommend. And I could refer you to a patient advocate who could do that work.

That would be great.

They charge an hourly rate, but they. They could take all those bills, they could price everything out. And then the other thing I would ask is, does that patient maybe qualify for financial assistance?

Okay, thank you.

Yeah, we'll. We'll talk. Michelle. So let's. I just emailed you tonight, so just write me back and we'll connect.

Marshall, we could ask you questions all night, but we. We should let you go. And we just want to thank you so much for taking the time to talk with us tonight. And also wanted to put in another plug just for joining the Free Market Medical Association. It's a great way to say that you are on board. And then you can also check out Marshall's website. He gave us the website in the substack in the chat, but he also has it's MarshallAllen.com, right?

Is the, that's my personal website. Personal website, I forgot to mention, we just announced a partnership with nabip, which used to be the national association of Health Underwriters and this is now NABIP members. I just put the link in the chat can get continuing education credit for doing the Never Pay Pathway videos. So if you're a broker and you're a NABIP member, you can get CPC credit for doing the curriculum. So that might be something that interests some of your, some of your audience. But thank you so much for having me here, everyone, and I'm easy to reach, so look me up on LinkedIn. I'm easy to find on my website. If you have any questions, just reach out to me. Have a great night. Okay, bye.

All right, thanks everybody, and have a great night.

Yes.

So all of our things are listed.

On there. What's upcoming.