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30 Matching News Items |
| 1. |
Craig Gottwals via Substack; registration may be required
Nov. 17, 2025
"Our member needed high-stakes surgery. The hospital knew it. The family knew it. Surgery was on the calendar; pre-op scans and imaging needed to be done. The message from the hospital was essentially: pay our inflated price, or the whole thing is at risk. When our repricer hit their bill with the 140%-of-Medicare logic, we weren't even in the same galaxy as their demand. They wanted ten times that amount. They wanted something no rational fiduciary could sign off on under ERISA's command to guard plan assets prudently."
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| 2. |
Craig Gottwals via Substack; registration may be required
May 14, 2025
"A recent federal court ruling ... quietly affirms that once a plan adopts a reasonable and consistent reimbursement methodology, fiduciaries may not just be allowed to decline provider negotiation -- they may be required to do so in order to protect plan assets and ensure uniformity across participants. That is, if your plan language is clear and your pricing structure is objectively defensible, engaging in post-claim negotiation may actually expose you to fiduciary risk." [Mejia v. Credence Mgmt. Solutions, No. 23-2028 (C.D. Calif. Apr. 21, 2025)]
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| 3. |
Craig Gottwals via Substack; registration may be required
Oct. 29, 2025
"Hospitals can do math. Combating a clear, prompt, and defensible payment requires staff time, letters, appeals, and sometimes legal counsel.... If your plan pays a transparent multiple of Medicare, if your language is precise, if your appeals correspondence is professional, and if your member advocacy is proactive, the hospital's marginal ROI on fighting you is poor. They often accept ... because you act like a payer with a system, and the effort isn't worth the benefit."
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| 4. |
Craig Gottwals via Substack; registration may be required
Oct. 6, 2025
"[Reference-based pricing (RBP)] isn't a toggle to the easy bottom. It's an entirely new operating system. It changes incentives, processes, and psychology. It's a direct assault on the two most powerful stakeholders in the largest segment of America's economy (healthcare): insurers and hospital chains. It works when you do it right, and it blows up when you wing it."
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| 5. |
Craig Gottwals via Substack; registration may be required
July 28, 2025
"[O]nly 14% of Americans think that health insurance plans should cover GLP-1s ... when they're prescribed solely for weight loss.... GLP-1s are already being overprescribed, and adding them for general weight loss in a self-funded plan is a fast way to blow a hole in your budget.... What if a very generous employer says, 'Look, we'll pay half of it.' ... And then the employer gives employees the choice ... No threat. No reduction. Just: 'Do you want to add this benefit and pay for it?' "
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| 6. |
Craig Gottwals via Substack; registration may be required
Sept. 3, 2025
"[Referenced-based pricing (RBP) is] one tool alongside direct primary care, cash-bundled payments at centers of excellence, selective contracting, transparent pass-through PBMs, and high-value physician-only networks.... Here are three recent, real-world RBP stories from three very different clients: [1] When RBP flows beautifully.... [2] When RBP is only a threat. [3] When RBP 'struggles' and still wins."
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| 7. |
Craig Gottwals via Substack; registration may be required
Aug. 12, 2025
"On one side, you've got stealth tactics masquerading as PPO networks. On the other, you've got AI-driven bounty hunters combing through mountains of closed claims in search of underpayments. Neither side would exist were it not for the grotesquely unsustainable price-fixing insurers and hospital systems rammed down the throats of employers and patients alike. It's a charade built upon a fantasy, manipulating the system that everyone hates, yet is overwhelmingly afraid to leave for something new."
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| 8. |
Craig Gottwals via Substack; registration may be required
Mar. 4, 2025
"This memo examines the legal framework governing hospital pricing disputes ... where a patient has agreed to pay for medical services but was not provided with a specific price beforehand.... The primary focus here is how courts evaluate hospital charges' enforceability and whether patients or insurers may be compelled to pay the full chargemaster rate. The analysis extends to the role of Reference-Based Pricing (RBP) health plans, particularly those governed by ERISA ... This memo assesses the legal standing of such plans in disputes over hospital pricing."
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| 9. |
Craig Gottwals via Substack; registration may be required
May 5, 2025
"there are only three entities in the U.S. that ultimately pay for healthcare: [1] The government/taxpayer (via programs like Medicare, Medicaid, or the VA); [2] Insurance companies (as the actual payer in fully insured and individual-market plans); [3] Employers (when they self-fund and become the payer directly). And among those three, the employer is -- by far -- the least conflicted and the most amenable to optimization."
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| 10. |
Craig Gottwals via Substack; registration may be required
May 12, 2025
"[HIPAA's] outdated definitions and narrow scope have created a gaping hole -- one that data brokers, app developers, retail pharmacies, and even your stop-loss underwriter are sprinting through with glee. And the worst part? This data dragnet ... [is] making your health plan more expensive, less accurate, and more vulnerable to being rated and lasered based on guesswork."
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