[S2E7] Mark Flores - The Healthcare Black Hole

Recovering Millions in Mismanaged Employee Benefits

When employers sign healthcare contracts, they assume they're getting what they pay for. Mark Flores, Vice President and Co-Founder of AVYM Corporation, reveals a disturbing reality: most employers are losing 15-30% of their healthcare spend to undisclosed fees and systematic billing errors—and they don't even know it.

In this eye-opening episode, Mark walks Vincent through his experience as a key architect of a landmark $100 million settlement against Horizon Blue Cross Blue Shield of New Jersey, exposing how insurance carriers operating in hybrid arrangements acting as both provider and administrator create inherent conflicts of interest that cost employers millions. 

Mark explains why most companies lack the independent resources needed to verify claims and fees, leaving them unable to fulfill their fiduciary responsibilities to employees. From the "lesser of" provision violations to the cultural shift employers need to make, this conversation delivers practical insights on protecting your organization's healthcare investments and ensuring employees receive the benefits they've earned.

About Mark Flores: Mark Flores is Vice President and Co-Founder of AVYM Corporation, a leading consulting firm specializing in medical claim transactions and ERISA-governed health plan compliance. Recognized by courts and regulators as a subject-matter expert, Mark has pioneered claims validation and recovery programs that have saved self-insured health plans millions while identifying fiduciary breaches and systemic inefficiencies.

About Vincent Catalano: Vincent Catalano brings over 23 years of employee benefits experience as an independent consultant and host of The CLEARly Beneficial Podcast. His unique position outside corporate constraints allows him to have frank conversations about healthcare issues that others can't address.

This episode is brought to you by HealthNEXT. HealthNEXT partners with employers to transform their employee health benefits through innovative, results-driven solutions that prioritize both cost savings and improved health outcomes.

Disclaimer: The information provided in this podcast is for educational and informational purposes only and should not be construed as legal, financial, or professional advice. Listeners should consult with qualified professionals regarding their specific situations.

Transcript

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Welcome to the Clearly Beneficial podcast,

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the show where we rip off the Band-Aid and explore the future of healthcare,

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benefits,

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and the people driving innovation in the industry.

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This episode is brought to you by Health Next,

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the company leading the way in helping employers build enduring cultures of health

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and well-being,

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reducing medical cost trends,

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and increasing organizational performance.

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To learn more how they can help you, visit healthnext.com.

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Hey, everybody, and welcome to the Clearly Beneficial podcast.

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And I'm super excited today to have somebody I think is a real innovator in

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healthcare and in a place and doing a thing that is not going to be obvious to a

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lot of folks in what he does,

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but he's making some waves in the industry,

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and I'm excited to have him.

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So Mark Flores with AVIM, thanks so much for being here.

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Thanks, Vinny.

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Appreciate it.

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Glad to be here.

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Well,

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it's interesting because you and I got to know each other,

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it seems like earlier this year through some mutual connections.

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And as I was,

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you know,

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putting together the podcast this year,

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you were on the top of my list to have someone to have as a guest because I saw

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what you were doing and I understood what you were doing in the market.

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And I'm like,

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damn,

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somebody's finally,

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you know,

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trying to challenge the fox who's guarding the hen house.

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So, you know,

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Chris,

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before we get into that,

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why don't you tell me a little bit about your background and the origin story a

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little bit.

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Sure, sure.

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So we're based on the West Coast, the left coast in LA.

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By the way, you probably noticed I'm drinking water from my championship mug here.

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Awesome.

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And we've been around, this iteration of our business has been around since 2011.

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So it was at 24 years or so, excuse me, 14 years.

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And before that, we were involved in my family business.

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My folks were in a claims billing and review company on behalf of providers,

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doctors and hospitals.

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So that's kind of where I cut my teeth in this sector.

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I got to learn about claims processing and payments and reimbursements from the provider side.

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Fast forward a few years and I think it was the Affordable Care Act that passed.

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Yeah, it was Affordable Care Act.

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And we kind of realized that employers were going to be held accountable on how

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they were adjudicating their claims.

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So we kind of

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pivoted, I guess, to include employers as potential clients.

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Now, you're probably thinking that seems kind of counterintuitive.

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Those groups, the employers and the doctors are typically at odds with each other.

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But we kind of realized from the beginning that

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The employers and the doctors should be friends because they were both sending

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money into this black hole,

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which is the two sides of the same coin.

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Exactly.

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So that's kind of how this whole concept evolved.

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You know,

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in the very beginning,

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you know,

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it was tough because they would look at us and say,

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you work for those greedy doctors.

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Oh, you know, we don't want to deal with you guys on the employer side.

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So we had to really.

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really do the work and really plow the field, so to speak, and plant these seeds.

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Luckily for us over time, things have changed.

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You know,

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some of the stuff we were involved with,

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some of the stuff we weren't,

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but now today people start to see the light and realize that,

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yeah,

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there's potentially issues going on in the employer side of the healthcare claims

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transactions.

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No.

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And,

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and,

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you know,

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for the listeners,

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I want to make sure that,

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that I want you to stay hooked here because I,

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What Mark is doing,

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you know,

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you hear words like,

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I mean,

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I always jokingly say I can say the word deductible and I can hypnotize you to

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sleep.

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Okay.

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But in this case,

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we're going to use the word claims and claims management and all that stuff as

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another word that can put you to sleep.

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But let me tell you,

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this episode is not going to put you to sleep because there's so much intrigue.

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that is going on that most people in the industry,

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brokers,

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providers,

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employers,

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have no idea what the deal is.

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So we're going to be digging into a lot of that.

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Because I love this origin story, Mark, because

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It's like it's a family.

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It was a family business.

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You learn claims because your folks were in it.

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And that literally speaks to, you know, 0.0001% of the population.

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I mean, you're like a unicorn for that.

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Not only that, but it was from the other side.

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It was from the enemy.

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Yeah.

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Yeah.

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yeah yeah so um so it's interesting so so um where i'm going to frame the

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conversation today is you know when you and i met i immediately because as having

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been a broker for over 20 years i immediately knew where you were coming from you

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know i was always like i was the guy as a broker who would like sit there and i

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would review the large claims from my clients and i would go huh and i'll never

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forget the time i saw a claim two

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quarter million dollar broken legs.

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And those are being attributed to my client.

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And I was like, what could have caused two $250,000 claims for broken femurs?

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And it turned out it was an auto accident, yet the insurance company simply paid the claim

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And they didn't do any diligence on whether there was somebody to subrogate against

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to get that money back and not blame my employer for it.

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So instead of my employer being on the hook for half a million bucks,

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I was able to get that claim waived and had that insurer go after it for the auto

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insurer who was part of the claim on the other side.

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And I'm sure you see that all the time.

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Yep.

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The only caveat would be we see it,

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but where we see it,

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we see it where the employer paid the claim.

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Right.

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But the doctor or the hospital never got paid.

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Oh, and that's where this whole thing gets more interesting.

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Right.

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That's a little different.

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No, this is where it all gets very interesting.

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So what excited me about talking to Mark is,

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you know,

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and I was jokingly telling him before we started,

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we're going to call this the F word claim.

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episode and the f word that i'm talking about today is fiduciary and and and maybe

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mark give us some perspective on on what that really means an employer

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should be mindful of the money they are spending on behalf of their employees, right?

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And that makes them a fiduciary?

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Yeah, so that's a $10 word that gets thrown around a lot.

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And really simply stated,

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a fiduciary is somebody who's supposed to act in the best interest of their members

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or participants.

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So what does that mean?

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That means as an employer, do I go out and shop the cheapest vendor?

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Maybe.

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But is that affecting or adversely affecting the employees?

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Is it better for the employees if I get a vendor who's a little bit more expensive,

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but that vendor does maybe has more services that protect the employees?

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So as a fiduciary, you're required to do what's best for your members or your participants.

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But at the same time,

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and this is where it's difficult,

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it's a balancing act,

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they have to act reasonable with respect to the expenses.

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So at the same time,

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they can't go out and get the Rolls Royce of vendors,

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you know,

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if they can get a Toyota vendor who is going to do the same service for half the

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price.

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So it is a bit of a balancing act.

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But at the end of the day, most employers don't have a problem shopping for price.

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But a lot of times they do have a problem comparing services for services,

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which is where consultants and advisors and maybe even brokers come in to help the

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employer kind of make sense of these various services and the different services so

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that they can really get a sense of comparing apples to apples versus,

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you know,

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something that's completely off the wall.

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Right.

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And so but wasn't there also some federal legislation in the last couple of years

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that that has highlighted

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the role of the fiduciary that there is,

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and I forgot the designation,

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maybe talk a little bit about that.

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So I'm gonna go into the alphabet soup of regulations here,

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but in the 70s,

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they created ERISA,

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which is the Employee Retirement Income Security Act.

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And the reason they created that law was,

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to protect the benefits that employees and their dependents and spouses get from

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their employers.

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So those rules have been around for a long time.

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I think the rule or the law that you're referencing came,

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I think it was the first Trump administration that passed,

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and that was called the Consolidated Appropriations Act.

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And essentially what that tried to do was create transparency.

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They basically said, look, doctors, hospitals, you've got to post your rates.

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Employers,

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you've got to find out what fees you're paying,

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and you've got to make an attestation to us every year that you looked at your fees

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and that you can attest that your fees are reasonable.

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And this is obviously an oversimplification, but basically there's some other...

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issues that were addressed with that law.

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But as far as the employers are concerned and relate to our discussion,

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those are the two main issues.

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So number one, the employer has to

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be able to see their fees and make a determination as to whether those fees are

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reasonable and then file this thing called an attestation.

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It's a declaration.

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So that's important because the employer has the responsibility and obligation and

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the liability if they don't do it.

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Well, what's the big problem with that?

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It should be the employer, right?

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Well,

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maybe not because most of the employers have delegated those responsibilities to

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their administrators.

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And that's what's created this kind of disconnect where the carriers,

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for example,

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or the administrator,

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they're not bound by the CAA necessarily.

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It's the employer who has the obligation,

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the fiduciary obligation,

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as a matter of fact,

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to make the attestation that the fees are reasonable.

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Now,

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if the employer can't see the fees,

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then how can they possibly say that the fees are reasonable,

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right?

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And that's kind of the big problem in this whole...

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But also those fees ostensibly roll down to the employee,

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right?

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Because that employee is going to be responsible for paying...

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health insurance out of their pocket potentially, and any number of claims out of pocket costs.

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And so I always joke that COBRA,

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for example,

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you know,

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most employees in a company don't know that they are a COBRA compliance officer.

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If they don't get the initial notice on the right time,

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if they don't get the termination notice at the right time,

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if they don't get enrolled properly,

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if they elect COBRA.

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So there's a lot of

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arcane rules.

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And this is why brokers, the crazy ones still do it, take that COBRA administration in-house.

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And the ones I worked for, we got rid of it.

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We used to bring in third-party administrators to administer the COBRA to shift the risk.

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But where I'm going with this is

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Cobra, an employee, very rarely would an employee say, man, I never got my notice.

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Oh, and all the things would go wrong.

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They themselves turn into Cobra compliance agents.

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Do employees sort of play the same role with fiduciary responsibility?

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Do they have, quote, standing to say, my employer is not acting as a fiduciary?

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So that's a good question.

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And I would say yes.

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And I look at this from two different perspectives.

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The first perspective is,

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hey,

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I'm getting screwed and my employer is not doing their job to protect me.

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They're not acting my best interest as a fiduciary.

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I'm going to call them out.

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I'm going to call them out.

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Okay.

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Okay.

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The other perspective is the employers,

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the employees,

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excuse me,

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don't forget,

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are also typically nowadays making contributions out of their paychecks to their

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benefits.

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So a lot of that money or a certain percentage of that money is their money as well

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as the employer's money in the self-funded space,

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right?

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So now...

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The flip side of that is if the employer is not monitoring and overseeing the plan

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assets,

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they're potentially harming the members.

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Because some of that money is theirs.

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Right.

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So it's this weird, again, this weird balancing act that the employers have.

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They have to make sure that they're protecting their members.

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They have to make sure that they're monitoring the plan assets.

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And a lot of times it's difficult.

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Now,

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if you're thinking about is the employee a kind of a monitor,

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so to speak,

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or are they kind of a guardrail?

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Right.

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You know, that really hasn't been our experience.

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And the reason is, think about what this is.

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These are benefits for healthcare.

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Yep.

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When an employee is using this benefit, there's something wrong with them.

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Heaven forbid it's a catastrophic illness or some serious chronic acute disease,

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but their concern is getting better.

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Their concern is getting well or their kid or their wife or their husband.

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They're not necessarily concerned about, did they check off all the boxes?

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Did I get all my notifications?

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Now, when the claim isn't paid,

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Of course, that triggers all the alarm bells.

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And so in a sense, that happens.

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But even in those cases,

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it's difficult for the employees to really act as a guardrail because of the

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nature.

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Well, they don't know.

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They're not educated and they don't know.

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I mean,

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most employees couldn't tell you an iota about COBRA,

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let alone something,

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another layer,

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which is fiduciary responsibility.

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So I want to dig into sort of a little bit of the nuts and bolts as to when your

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company has an opportunity to help someone.

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And I thought it was like when I first learned about this, it was like the coolest thing.

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So for the listener,

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you know,

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I want to say we're going to get maybe a little bit arcane in sort of how health

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plans are funded because you're now going to learn something that,

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you know,

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99.9% of the population doesn't know.

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Okay.

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Okay.

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I mean,

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when an employer buys insurance,

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health insurance for their employees,

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they can do it in a number of ways.

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The simplest way to do it is called fully insured.

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Employer writes a check to an insurance company.

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Insurance company provides insurance to the employees.

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Everything is run by the insurance company and the employer doesn't get involved in

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much of the detail.

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Okay, they just take what's off the shelf of what an insurance company offers.

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On the other side of the equation is something called self-funding.

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Self-funding is where an employer says, hey, we're gonna pay the claims up to a certain amount

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And then after that amount,

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we have what's called stop loss insurance to protect us against the high claims.

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But in the meantime,

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we're going to use our cash flow to pay for claims as they are incurred by our

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employees.

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And so the advantage of that, there's certain tax advantages to that.

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There's some flexibility to that.

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in california for example these plans are subject to federal law not state law so

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there's certain mandated benefits that that don't end up in in those plans that's

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you know in in in certain instances but i i jokingly say you know if you you know

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the the the lamborghini is either paid for by the by fully insured you're buying a

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fully built Lamborghini over here in self-insurance you're literally billing the

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lamborghini yourself

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You're picking the insurance.

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You're picking the stop loss.

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You're picking the network.

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You're picking the pharmacy.

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You're picking a whole bunch of things, and you're slapping it on the chassis.

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But then there's this little,

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not eensy-weensy,

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but a pretty big niche in the middle where enterprises,

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normally with companies or municipalities with 10,000 or more people or even

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smaller,

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but let's start with that,

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with 10,000 or more employees' play,

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And that's sort of, I call it hybrid land.

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Okay,

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that's where I call the fox guarding the hen house,

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where the employer contracts with an insurance company that is the one also selling

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a fully insured contract,

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and they themselves buy a self-insured contract from that insurance company.

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So the insurance company is really taking everything they have off the shelf,

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but wrapping a different financial structure around it

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in order to have the employer have the tax benefits and ERISA and all these other

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types of things.

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Did I get that mostly right, Mark?

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Yeah, so let me, that's a good question.

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So let me just add a little clarification.

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The funding structures themselves

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are not necessarily tied to whether it's federal or state law.

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And the reason is you could have self-insured, as you said, state benefit health plan, right?

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That's not subject to ERISA.

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That's subject to state laws, right?

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The point is,

(00:17:54):
The funding mechanism is really the key aspect because, and I'll use your Lamborghini example.

(00:18:01):
I love that example.

(00:18:02):
Even though I hate comparing health insurance to auto insurance,

(00:18:06):
for the funding mechanism,

(00:18:07):
I think it's a good analogy.

(00:18:09):
And the funding mechanism is very simple.

(00:18:11):
You buy auto insurance,

(00:18:12):
particularly here in California,

(00:18:14):
and after your 30-day grace period,

(00:18:17):
you pay $300 a month.

(00:18:19):
And, you know, the second month you crash your car and it costs $10,000 to fix your car.

(00:18:25):
It doesn't matter.

(00:18:26):
You paid your $300 premium.

(00:18:29):
The insurance company now is stuck paying the $9,700 balance, right?

(00:18:34):
Because you paid $300 to fix your car.

(00:18:38):
But that's an insurance policy that's fully insured.

(00:18:42):
The difference is if you were to buy a self-insured type contract policy through

(00:18:49):
your car insurance company,

(00:18:51):
you would have to have pre-funded your policy with the amount that your car is

(00:18:57):
worth.

(00:18:58):
So if they would have said, okay, you're going to buy this policy.

(00:19:01):
Great.

(00:19:01):
We need a check for 10 grand.

(00:19:02):
You're like, what do you mean?

(00:19:03):
Well,

(00:19:04):
you're paying for this.

(00:19:06):
So if you crash your car tomorrow, I'm not gonna pay this, you gotta pay it.

(00:19:10):
So I need you to pre-fund 10 grand

(00:19:14):
In case you crash your car,

(00:19:15):
oh,

(00:19:15):
and by the way,

(00:19:16):
every month thereafter,

(00:19:17):
you're going to pay me 500 bucks,

(00:19:19):
okay?

(00:19:20):
That's the fundamental difference.

(00:19:22):
That's how I would, the analogy I would use.

(00:19:25):
Now,

(00:19:26):
going to your question about these administrators who are administrating these

(00:19:31):
self-funded,

(00:19:33):
pre-funded,

(00:19:34):
right,

(00:19:35):
insurance policies or plan benefits.

(00:19:38):
You know, the culture is simple.

(00:19:40):
You know, you're on a member employee plan.

(00:19:43):
I'm on the same plan.

(00:19:44):
Mary's on the same plan.

(00:19:46):
Joe's on the same plan.

(00:19:47):
We're all kicking in a hundred bucks.

(00:19:49):
That's our money.

(00:19:51):
You know, Joe goes to the doctor for a broken fingernail and he gets a thousand dollar bill.

(00:19:57):
You know, we're going to tell Joe, hey man, knock it off, dude.

(00:20:00):
That's our money too.

(00:20:02):
Like, you know, why are you going to the doctor for a broken fingernail, right?

(00:20:05):
So it's the same concept, same idea.

(00:20:08):
The same concept is that the employers want to try to protect that money.

(00:20:13):
They want to try to prevent some of these employees from,

(00:20:17):
you know,

(00:20:19):
using these services for frivolous care that they maybe don't need,

(00:20:23):
right?

(00:20:23):
Now, that's the general idea behind how this works.

(00:20:28):
You want to protect those assets and make sure they're available for catastrophic illnesses.

(00:20:32):
But now when you're talking about the administrator...

(00:20:37):
Employers will typically hire an administrator.

(00:20:40):
Sometimes they're large national carriers.

(00:20:43):
Sometimes they're regional.

(00:20:44):
They call them TPAs, third-party administrators.

(00:20:47):
It just varies.

(00:20:49):
Sometimes they self-administer.

(00:20:50):
Certain unions do that.

(00:20:52):
And the idea behind that is, hey, I make truck parts.

(00:20:58):
I don't know anything about health care.

(00:21:00):
I'm hiring you for your expertise to make sure

(00:21:04):
That my members, A, get the care they need.

(00:21:06):
But B,

(00:21:07):
you know,

(00:21:07):
if you see some of my members going to the doctor for ridiculous stuff,

(00:21:11):
let me know.

(00:21:12):
And B and C,

(00:21:13):
you know,

(00:21:13):
if you see some of these charges coming through that are crazy,

(00:21:16):
let me know.

(00:21:18):
It's real simple, right?

(00:21:19):
Yeah.

(00:21:20):
But that's not what happens.

(00:21:22):
What happens,

(00:21:23):
at least in our experience,

(00:21:24):
is the employers hire these administrators and the administrator,

(00:21:29):
don't worry,

(00:21:29):
I'll take care of everything.

(00:21:31):
When the employer has a question about a claim or expenses,

(00:21:35):
the administrator gives them information that in some cases doesn't really truly

(00:21:42):
accurately represent the specific charges from the doctor or the specific payment

(00:21:50):
to the doctor.

(00:21:51):
So you're probably asking me like, wait a minute, Mark, what are you saying?

(00:21:56):
If that's not, if it doesn't represent that, what does that mean?

(00:21:59):
Well, what that means is that typically there's fees built into these services.

(00:22:05):
And a lot of times the fees are taking as part of the claim dollars.

(00:22:09):
So if the doctor bills,

(00:22:11):
you know,

(00:22:11):
a thousand bucks and the insurance company or the TPA says,

(00:22:15):
hey,

(00:22:15):
I have to charge you a small fee for this.

(00:22:17):
Maybe I have to charge you a hundred bucks, right?

(00:22:21):
So now the $1,000 bill goes through,

(00:22:24):
but the insurance company needs a $100 fee,

(00:22:26):
so that bill has to be $1,100.

(00:22:29):
The $1,000 payment plus their $100 fee.

(00:22:32):
You follow?

(00:22:33):
I completely follow.

(00:22:34):
I'm sorry.

(00:22:38):
But that's how you can get a claim dollar amount that is above what the actual

(00:22:43):
claim payment is or should be.

(00:22:48):
Well, isn't it true?

(00:22:49):
If I recall,

(00:22:50):
one of our early conversations,

(00:22:51):
it even gets a lot more egregious than your $100 example,

(00:22:56):
right?

(00:22:56):
It gets to the point where,

(00:22:59):
you know,

(00:22:59):
the middleman,

(00:23:00):
meaning the carrier-based,

(00:23:02):
insurance company-based,

(00:23:04):
you know,

(00:23:04):
administrator is saying,

(00:23:06):
okay,

(00:23:07):
well,

(00:23:07):
you know,

(00:23:07):
Joe went and got a new knee at the surgery center.

(00:23:11):
The surgery center, you know, billed $5,000 for the knee.

(00:23:16):
they build the insurance company,

(00:23:18):
they adjudicate the claim,

(00:23:19):
and they go,

(00:23:19):
well,

(00:23:20):
on our fee schedule,

(00:23:21):
we're only going to pay you $2,500.

(00:23:22):
And so they have documentation from the surgery center saying,

(00:23:31):
you know you owe us 5 000 but now we're only going to pay you 2 500 because that's

(00:23:36):
our contracted rate but yet what they bill the employer for that procedure is the

(00:23:42):
five thousand dollars is that accurate yes so this is really we're simplifying this

(00:23:50):
process there's all kinds right i i know that but i i for the listener i i want to

(00:23:54):
make sure that the broad listener

(00:23:57):
kind of grasps the deal.

(00:23:59):
So there is going to be typically a fee in the contracted rate as well, right?

(00:24:03):
So it might not be 2,500, half, you know, 50%, that's a lot.

(00:24:08):
But maybe the bill's 5,000, the contracted rate's 2,500.

(00:24:14):
So they take 3,000 from the employer.

(00:24:17):
So it's maybe, you know, 500 bucks, right?

(00:24:20):
20% fee.

(00:24:21):
Okay, that's a lot.

(00:24:22):
But what about if you're non-contracted?

(00:24:25):
What if you're out of network?

(00:24:27):
Now what?

(00:24:28):
Now the 5,000 bill comes in.

(00:24:30):
There's no contract.

(00:24:32):
Do they pay the surgery center 5,000, the full bill charges?

(00:24:37):
No, not usually.

(00:24:39):
Rarely, if ever, do they pay.

(00:24:41):
But yet they turn around and tell the employer,

(00:24:44):
oh,

(00:24:44):
I need 5,000 bucks because there's no discount on this claim because this guy's out

(00:24:50):
of network.

(00:24:51):
Now, what they'll do is they'll say, guess what, Mr. Employer, you're in luck today.

(00:24:55):
Why?

(00:24:55):
Because I'm going to go down there and I'm going to negotiate and make a deal with

(00:24:58):
this doctor and save you money.

(00:25:01):
So the employer gets happy and says, oh, you're going to save me money.

(00:25:04):
Yes, I am.

(00:25:05):
But I'm going to charge you a percent of the savings.

(00:25:09):
Now, on the surface, that sounds cool.

(00:25:11):
That sounds great.

(00:25:12):
You're going to go fight for me.

(00:25:13):
You're going to go grind these greedy doctors down.

(00:25:16):
You're going to make their bill reasonable and you're going to save me money.

(00:25:19):
Great.

(00:25:21):
But there's only one problem with that.

(00:25:23):
Number one, how do you determine the savings amount?

(00:25:27):
What is considered savings?

(00:25:28):
Right.

(00:25:29):
And I'll give you an example.

(00:25:31):
If I, I'm a man, a male, right?

(00:25:35):
If I go into a hospital and I get a gynecological procedure, right?

(00:25:39):
They do a gynecological procedure or they at least bill for that.

(00:25:44):
Right.

(00:25:44):
Maybe they don't do it, but they bill it.

(00:25:46):
Right.

(00:25:47):
Right.

(00:25:47):
So now the insurance company gets the bill and they look at the bill and they say,

(00:25:51):
wait a minute.

(00:25:53):
Mark is a guy.

(00:25:55):
We don't see any record of any sex change operations here.

(00:25:58):
They're sending a bill in for a gynecological procedure, okay?

(00:26:03):
The insurance company would normally say, that's not covered.

(00:26:07):
We're rejecting this claim.

(00:26:08):
We're denying it or rejecting it.

(00:26:10):
It's not covered at all.

(00:26:12):
There is no negotiating.

(00:26:13):
There's nothing.

(00:26:14):
We don't cover that, right?

(00:26:16):
Right.

(00:26:17):
Now,

(00:26:17):
what if the insurance company says,

(00:26:19):
or the TPA,

(00:26:20):
excuse me,

(00:26:21):
says,

(00:26:22):
hey,

(00:26:22):
Mr.

(00:26:22):
Employer,

(00:26:24):
we got a claim from Mark.

(00:26:25):
It was $10,000 for a gynecological procedure, but we paid zero.

(00:26:30):
And guess what, Mr. Employer?

(00:26:32):
We saved you 10,000 bucks.

(00:26:36):
Is that right?

(00:26:37):
Does that make sense?

(00:26:38):
That makes sense.

(00:26:39):
Sure.

(00:26:40):
It does?

(00:26:41):
Okay.

(00:26:42):
It doesn't make sense because they didn't save them anything.

(00:26:44):
It was something that should just been rejected out of hand.

(00:26:46):
Exactly.

(00:26:47):
Right.

(00:26:47):
And that's the fundamental problem with these shared savings programs.

(00:26:51):
It's very,

(00:26:52):
very difficult to figure out what should have been paid,

(00:26:56):
what shouldn't have been paid.

(00:26:58):
what the discount really is what how are you basing the discount is it based off of

(00:27:02):
bill charges is it based off of some contracted rate is it based on you know some

(00:27:07):
other number that i have no idea what you're using you know and then not only that

(00:27:10):
but if i can't see as an employer what the actual payment amount is well then how

(00:27:16):
can i ever confirm or validate that the discount amount and the fee you charge me

(00:27:22):
is correct

(00:27:23):
Right?

(00:27:24):
So there's a lot of inherent problems with that model.

(00:27:27):
And that's one of the things that we look at when we are hired by employers.

(00:27:33):
And so now it's, you know, you put on your miner's hat and you start to dig through.

(00:27:41):
And I would imagine that

(00:27:43):
for an enterprise that's processing that 10,000 plus employees that has thousands

(00:27:49):
upon thousands of claims a year.

(00:27:51):
I mean,

(00:27:54):
when you sift through,

(00:27:55):
and I'm asking you to probably make a very broad general statement here,

(00:27:58):
but when you sift through the wreckage

(00:28:01):
if you have access to the data,

(00:28:02):
which I'm sure is a whole other conversation,

(00:28:04):
but if you get access to the data and you're sifting through all the information,

(00:28:09):
what percentage of claims would you potentially find as actionable to fall into

(00:28:18):
question?

(00:28:21):
So this is only based on our own historical experience.

(00:28:26):
And we're looking at conservatively 15% up to 25, 30%.

(00:28:36):
So what does that really mean?

(00:28:38):
So the way we assess this questionable claim spend amounts, right?

(00:28:44):
We base that on the actual claim spend itself.

(00:28:48):
So if you're an employer and you're spending a million dollars a year on medical claims,

(00:28:55):
This doesn't include your PMPM fee.

(00:28:57):
This doesn't include commissions.

(00:28:59):
You know, those are all itemized separately.

(00:29:01):
This is just what the insurance says you paid in medical claims this last year,

(00:29:05):
a million bucks,

(00:29:07):
right?

(00:29:08):
We are typically seeing anywhere from 150,000 to 300,000 of that million,

(00:29:11):
which is- And a million is nothing.

(00:29:13):
I mean, in terms of-

(00:29:20):
group size,

(00:29:22):
if you're at a 10,000 employee level,

(00:29:24):
you're looking at,

(00:29:28):
could be 50 million,

(00:29:29):
could be 100 million in total claims dollars.

(00:29:34):
So let's look at the 100 million number.

(00:29:36):
So what we're looking at is between 15 and 30 million per year of the 100 million

(00:29:42):
spend is potentially fees that haven't been disclosed to you.

(00:29:51):
And this is stuff that just goes on every day.

(00:29:58):
Right.

(00:29:59):
So the next question I typically get asked is, well, is this a one-off?

(00:30:04):
Are these exceptions?

(00:30:05):
How often does this happen?

(00:30:08):
Usually they ask, what's the percent of employers that this is happening to?

(00:30:14):
Out of 10 employers, how many is this happening to?

(00:30:17):
And based on our experience, eight out of 10.

(00:30:22):
Wow.

(00:30:23):
So that's a very big statement in that in my old age,

(00:30:30):
I guess I've just gotten a little jaded about the business in general,

(00:30:33):
but hence why I'm doing the podcast is to shed light on stuff that people like you

(00:30:40):
are doing.

(00:30:42):
And I just view that this industry,

(00:30:44):
healthcare,

(00:30:45):
employee benefits,

(00:30:47):
in many ways,

(00:30:48):
I see it as the blind leading the blind.

(00:30:52):
and you've got a broker who's involved who is interested in their paycheck,

(00:30:58):
You've got an HR person who,

(00:31:00):
bless their heart,

(00:31:01):
is overworked,

(00:31:02):
underpaid,

(00:31:03):
you know,

(00:31:05):
should be really engaged in benefits.

(00:31:08):
A lot of them aren't educated on benefits, certainly not the arcane financing of benefits.

(00:31:15):
And so I think a lot of those are not as engaged on the money side as they could be.

(00:31:21):
You take the finance side of any company, CFO, et cetera, controller,

(00:31:26):
They,

(00:31:27):
it's interesting that the cultural issue here,

(00:31:30):
culturally CFOs and others in the financial side of the house have abdicated their

(00:31:35):
responsibility of the health plan to HR.

(00:31:38):
So there's nobody really minding the store, and the CFO is running the business, right?

(00:31:45):
And so there is a need almost,

(00:31:48):
and I've tried to say this for a couple of years now,

(00:31:52):
that there just needs to be almost a cultural revolution around who's minding the

(00:32:00):
store about the cost of healthcare and benefits,

(00:32:04):
right?

(00:32:05):
Yeah,

(00:32:05):
and let's go back to this earlier analogy we made about Joe who's going to the

(00:32:09):
emergency room every week for his broken fingernails,

(00:32:12):
right?

(00:32:13):
The whole company's mad at Joe because he's wasting money.

(00:32:17):
But meanwhile, they're bleeding 20% of their total claim span annually.

(00:32:22):
So it just shows you how the system is kind of tweaked and the narrative that's

(00:32:28):
been created is not entirely accurate.

(00:32:33):
You know what I mean?

(00:32:34):
Is Joe spending 20% of the claim spend?

(00:32:37):
With a broken fingernail, no way, likely not, right?

(00:32:42):
But yet they're blaming him.

(00:32:44):
And so that goes back to this idea that,

(00:32:46):
oh,

(00:32:46):
these high cost claimants,

(00:32:48):
these people who are sick,

(00:32:49):
they're driving all the expenses.

(00:32:51):
Yes, that's true.

(00:32:52):
They are driving expenses to a certain extent because the nature of their illness.

(00:32:55):
But are they really driving 80% of the spend?

(00:33:00):
If 20% of that is going out to a fee, I mean, what does that really mean?

(00:33:06):
How do you fix that problem?

(00:33:09):
And so that kind of leads me to the next segment or issue is what we try to do here

(00:33:16):
is simply create transparency.

(00:33:18):
That's really all we're trying to do.

(00:33:20):
We don't engage a client, an employer client and tell them,

(00:33:25):
oh my God, we think you're getting ripped off, you're getting screwed.

(00:33:28):
If they ask us what our historical findings have been,

(00:33:30):
we'll be honest with them,

(00:33:31):
but we're not going in there looking for fraud.

(00:33:34):
We're simply going in there to say, look, what does your contract say?

(00:33:38):
What are the terms in your contract?

(00:33:40):
Are any of the terms in your contract potentially problematic for you?

(00:33:45):
Number two, are you getting any data?

(00:33:48):
Any data?

(00:33:49):
You are?

(00:33:50):
Great.

(00:33:50):
Let's take a look at this data.

(00:33:52):
Let's ask questions about this data.

(00:33:54):
You're not getting any data?

(00:33:55):
Fine.

(00:33:56):
Let's go get some data.

(00:33:57):
Yeah.

(00:33:58):
And let's look at this data.

(00:33:59):
Number three, we're finding problems with this data.

(00:34:02):
Can we fix it?

(00:34:04):
What's the remedy?

(00:34:05):
You know, maybe there are no problems.

(00:34:07):
Maybe there's either those eight,

(00:34:09):
you know,

(00:34:09):
10 employers,

(00:34:11):
we get two of them that,

(00:34:12):
oh,

(00:34:12):
it's pretty clean.

(00:34:12):
It's pretty straightforward.

(00:34:13):
Everything's clean.

(00:34:14):
You're okay.

(00:34:15):
You know, not to worry, right?

(00:34:17):
But if you're one of the eight,

(00:34:19):
What are you doing?

(00:34:20):
What's your remedy?

(00:34:21):
And this also goes full circle back to what you said earlier about fiduciary obligations.

(00:34:28):
Now,

(00:34:28):
most people,

(00:34:29):
even non-healthcare people,

(00:34:32):
would agree that,

(00:34:34):
yeah,

(00:34:34):
you should be able to go back and look at your spend and figure out if the invoice

(00:34:40):
is correct,

(00:34:43):
if the services were provided,

(00:34:45):
And the payment amount was the correct amount.

(00:34:49):
You hire a plumber.

(00:34:50):
He comes to your house.

(00:34:51):
He gives you a quote.

(00:34:52):
Hey, it's going to cost 300 bucks.

(00:34:53):
Great.

(00:34:54):
He fixes your pipe.

(00:34:56):
You charge a credit card.

(00:34:58):
Boom, you're done.

(00:35:00):
The next day, you look at the invoice.

(00:35:02):
You say, okay, he charged me 300.

(00:35:04):
You go check your pipe.

(00:35:05):
My pipe is not leaking anymore.

(00:35:07):
Cool.

(00:35:08):
But then you see your credit card.

(00:35:09):
You see a $600 charge.

(00:35:12):
Like, wait a minute, something's wrong here, right?

(00:35:14):
Very simple.

(00:35:16):
There's no reason why the same thing should not be done and cannot be done in health care.

(00:35:22):
And I think that's the,

(00:35:23):
at least me personally,

(00:35:24):
I think that's the very first step before you really talk about making,

(00:35:30):
you know,

(00:35:31):
systemic changes or eliminating the middleman or the population health management,

(00:35:36):
redesigning the plan.

(00:35:38):
I'm going to get technical, right?

(00:35:39):
But before you go into all those very sophisticated solutions,

(00:35:42):
you really need to get an idea of what you're really spending.

(00:35:46):
on health care and i.e.

(00:35:48):
payments to the doctors absolutely absolutely and and that and that is you know

(00:35:54):
what that you know as you're talking i'm thinking about just even the average

(00:36:00):
member of a health plan okay you know they've now gone through some procedures a

(00:36:04):
multitude of things leading up to an illness all of a sudden the eob start coming

(00:36:09):
in evidence benefit forms start coming in bills start coming in and it is almost

(00:36:15):
physically and mentally impossible to match up the eob to the bill because

(00:36:22):
multitude of things could be on any one of those things and then people freak out

(00:36:26):
and then people get sent to collections because they don't really

(00:36:30):
know what the heck's going on you know because it's it's very stressful especially

(00:36:33):
now with with more high deductible plans and and other plan designs that are out

(00:36:38):
there the individual member of a health plan has has it's almost powerless but

(00:36:44):
whereas going with that was especially now where i mean everyone is when i started

(00:36:50):
in the industry

(00:36:53):
2003,

(00:36:53):
I could ensure a individual working for an employer for about 150 bucks a month,

(00:37:00):
400 bucks for a family.

(00:37:02):
Right here now, 2025, we've just about added a zero to both of those numbers.

(00:37:09):
I mean, the single premium for an employee on average is about a thousand bucks.

(00:37:13):
It's tipping $4,500 or more for a family.

(00:37:17):
And employers are sharing more of that cost with their employees because they can't

(00:37:22):
afford to pay for it all.

(00:37:23):
So there's more cost shifting.

(00:37:25):
Deductibles are going up.

(00:37:27):
Employers,

(00:37:29):
I think,

(00:37:30):
absolutely have an imperative to make sure that the money they are spending is

(00:37:35):
legit.

(00:37:36):
Because if what you're saying is true, and I have no reason to doubt you,

(00:37:43):
If an employer of an enterprise digs in and understands what's going on, well then,

(00:37:49):
You know,

(00:37:49):
if I can shave 20%,

(00:37:51):
pick a number,

(00:37:52):
15,

(00:37:53):
20% of my annual healthcare spend because of things that are being misrepresented

(00:37:59):
or overbilled or whatever it might be,

(00:38:00):
I can literally almost reset my health plan because my rates and everything are

(00:38:08):
going up 10% a year.

(00:38:09):
Well, I got to reset that somewhere.

(00:38:12):
And this is, I think, just one means by which it can be done.

(00:38:16):
you know,

(00:38:17):
there's a lot,

(00:38:18):
I don't wanna go down this road,

(00:38:19):
but you know,

(00:38:19):
there's a lot,

(00:38:20):
Mark Cuban is going off on a lot of pharmacy benefit managers and he's doing a lot,

(00:38:25):
you know,

(00:38:26):
raising the bar.

(00:38:27):
He put up a post that I commented on talking about employers fiduciary

(00:38:32):
responsibility for pharmacy.

(00:38:37):
And I commented and I said, why stop at pharmacy?

(00:38:41):
But what about the pharmacy represents 30% of the spend?

(00:38:44):
What about the other 70% of the spend, which is medical claims, you know?

(00:38:50):
Let's just say he liked the comment and it got a lot of views.

(00:38:54):
I think that's where that is an important thing for employers to recognize is that

(00:39:00):
there is money sitting on the table that's yours,

(00:39:04):
that you're spending that you should be able to claw back.

(00:39:08):
So I want to say- We call it couch cushion money.

(00:39:11):
The money you didn't know you had.

(00:39:12):
A lot of couch cushion money.

(00:39:14):
So again,

(00:39:15):
as we talked before we started the record,

(00:39:17):
I want to have you spend a couple of minutes

(00:39:20):
sharing what you wanna share.

(00:39:21):
You were involved recently in a large settlement,

(00:39:28):
saving an entity a huge amount of money and finding a huge amount of money.

(00:39:33):
And I'd like to give you an opportunity to talk a little bit about that to the

(00:39:38):
extent that you're comfortable and what's public.

(00:39:41):
Sure, sure.

(00:39:41):
So we were, myself and my other partner were involved.

(00:39:45):
We were the primary architects

(00:39:48):
of this case that was filed against Horizon,

(00:39:50):
Blue Cross Blue Shield Horizon,

(00:39:52):
New Jersey,

(00:39:54):
on behalf of the state of New Jersey.

(00:39:56):
I think they call it the SHIP program or the SHEP or something like that.

(00:40:01):
It's the employee, the state employee benefit health plan.

(00:40:04):
And it's pretty big.

(00:40:05):
It's a huge plan.

(00:40:07):
So we brought this case up.

(00:40:10):
The state of New Jersey attorney general took the case and ran with it.

(00:40:16):
God bless him.

(00:40:18):
And ultimately,

(00:40:19):
after the investigation,

(00:40:20):
after we kind of pointed them out to where to look,

(00:40:25):
they negotiated a hundred million dollar settlement with Horizon.

(00:40:31):
Wow.

(00:40:31):
And my understanding is that was the largest non-Medicaid settlement in state history.

(00:40:37):
Wow.

(00:40:37):
That's a big, big number.

(00:40:39):
I mean, that's a lot of money, right?

(00:40:42):
And how many employees were involved in that enterprise?

(00:40:46):
I think the state has a few hundred thousand employees, I believe.

(00:40:52):
But here's the takeaway.

(00:40:54):
The takeaway is,

(00:40:55):
and you kind of alluded to this earlier,

(00:40:58):
you know,

(00:40:58):
you don't have to believe me.

(00:41:00):
If you believe me, great.

(00:41:01):
But all you have to do is do a simple search and use a skeptical eye and you'll

(00:41:08):
find cases after cases or situations after situations of this type of activity

(00:41:15):
going on.

(00:41:16):
Now, in the Jersey case,

(00:41:18):
The state attorney general ultimately went after Horizon because they were not

(00:41:24):
complying with this thing called the lesser of provision,

(00:41:29):
which basically means if you have a bill come in,

(00:41:33):
but there's a contracted rate,

(00:41:35):
you theoretically have two different amounts,

(00:41:38):
we the state will always pay the lesser,

(00:41:39):
whichever is the lesser.

(00:41:41):
If the doctor bills low, we bill that.

(00:41:44):
If the contracted rate is lower than his billed amount, then we pay that, excuse me.

(00:41:48):
And so that was the essence of that lesser of.

(00:41:52):
It makes sense, right?

(00:41:54):
Ultimately, the state realized that they were not paying the lesser of.

(00:41:58):
They were in many cases paying the higher amount.

(00:42:03):
And the state in their press release, they mentioned that

(00:42:07):
when they had negotiated the contract with Horizon, Horizon had agreed to comply with that.

(00:42:13):
They said, don't worry, we'll take care of that.

(00:42:14):
We'll pay the lesser of.

(00:42:16):
But they didn't.

(00:42:17):
And when the state found out,

(00:42:19):
at least according to the court documents that I saw in the AG's press release,

(00:42:25):
Horizon said,

(00:42:25):
oh,

(00:42:26):
we're sorry,

(00:42:26):
we couldn't do it.

(00:42:28):
We didn't do it because our systems couldn't do it.

(00:42:31):
It wasn't because we didn't want to.

(00:42:32):
We just couldn't.

(00:42:34):
And, you know, of course, the A.J.

(00:42:36):
got even more upset.

(00:42:37):
He's like, well, why did you lie to me and say you couldn't do it, right?

(00:42:42):
So that was a huge piece of this, you know, settlement amount.

(00:42:46):
There was some other issues that were related to services that were not being provided, I think.

(00:42:52):
They were paying for certain services that were not being provided.

(00:42:55):
But that goes back to the plumber.

(00:42:57):
Hey, you billed me 300 bucks to fix my pipe.

(00:43:00):
Did you fix my pipe?

(00:43:01):
It's very simple, right?

(00:43:03):
So those were a couple of things that were specific to the Horizon case, the New Jersey case.

(00:43:10):
But all you have to do is, like I said, look online.

(00:43:12):
There's Tiara Yachts versus Blue Cross Blue Shield Michigan.

(00:43:16):
There's Owens Minor versus Anthem.

(00:43:19):
There's the...

(00:43:23):
There's one in,

(00:43:24):
I think it's in Massachusetts,

(00:43:26):
trustees,

(00:43:27):
labor and welfare trustees versus Anthem.

(00:43:29):
I mean, there's a lot of cases.

(00:43:31):
There's Aramart versus Aetna.

(00:43:33):
There's Kraft Heinz.

(00:43:35):
Everybody knows Kraft Heinz, big company.

(00:43:37):
They're fighting with their TPA, you know, insurance carrier, Aetna.

(00:43:41):
Those are all lawsuits, public information.

(00:43:44):
A lot of them unsettled,

(00:43:46):
which tells you if it settles,

(00:43:48):
then,

(00:43:48):
you know,

(00:43:49):
some of the stuff might have been...

(00:43:51):
True, right?

(00:43:52):
But it begs an interesting question.

(00:43:56):
And I'm just curious because I want to kind of,

(00:43:59):
you know,

(00:44:00):
sort of appreciate all that insight because it's so valuable to know that people

(00:44:05):
are,

(00:44:06):
you know,

(00:44:09):
fighting the good fight, let's just put it that way.

(00:44:12):
But it makes me think of like,

(00:44:13):
you know,

(00:44:14):
class action suits that get settled and all of a sudden,

(00:44:16):
you know,

(00:44:17):
someone wants to,

(00:44:18):
you know,

(00:44:18):
sell you,

(00:44:19):
you know,

(00:44:20):
give you a check for $4 because you were part of the class,

(00:44:23):
you know?

(00:44:23):
I mean, does any of that 100 million flow back to the employees?

(00:44:30):
Well, if it flows back to the employees, I can't answer that.

(00:44:33):
But I can tell you that a substantial part of, I think, 80%,

(00:44:37):
actually went back to the plan itself.

(00:44:40):
So that was money that went back into the pot to pay for these claims.

(00:44:44):
And I've seen a lot of articles and I see a lot of commentary about,

(00:44:48):
well,

(00:44:49):
it's so little bit and this and that.

(00:44:50):
But I think people are kind of forgetting the real point, which is, yeah, there's some money.

(00:44:57):
Maybe it's not enough or maybe there could have been more, but now the state is aware that

(00:45:02):
Now that they can mitigate this activity going forward.

(00:45:05):
And more importantly,

(00:45:08):
other entities that are involved in their own benefit plans should look at this

(00:45:13):
example and say,

(00:45:14):
maybe we should look at this too.

(00:45:16):
Maybe we should look at our own plans and our own providers just to make sure everything's fine.

(00:45:21):
I would imagine that as you're talking about larger enterprises,

(00:45:24):
starting to look at them,

(00:45:26):
probably large union plans should be looking at them,

(00:45:29):
large school districts.

(00:45:30):
I mean, anything with that number of 10,000 or more employees really should be looking at this.

(00:45:37):
and so no i mean it's it's uh it really i think is a is a great work that you're

(00:45:44):
doing when i first met you i was super impressed by you and what you guys are doing

(00:45:49):
because again it's you literally have you know you put your miners hat on and grab

(00:45:54):
your pickaxe and and you go after it and i would use the term forensic kind of way

(00:46:00):
um to just understand the money flow

(00:46:03):
who owns what, and if the client is deserving of some of that money back.

(00:46:08):
But more importantly, like you just said, it's creating a precedent for the future.

(00:46:15):
Once we've done the math,

(00:46:16):
once we've figured it out,

(00:46:17):
once we've looked behind the last couple of years,

(00:46:19):
now we look forward and we have safeguards in place so this doesn't happen again.

(00:46:24):
And I think that is super important.

(00:46:26):
And you're doing something in an area that

(00:46:32):
Nobody knows about.

(00:46:33):
So I'm happy to bring what you're doing to light and have the market understand

(00:46:38):
what you're working on.

(00:46:40):
Think of it, Vinny, as an intersection, a traffic intersection.

(00:46:46):
You have stop signs, right?

(00:46:48):
And you go through the intersection every single day on your way to work.

(00:46:52):
And over time, you stop stopping.

(00:46:55):
You just go right through it because there's nobody ever there.

(00:46:58):
You're in a hurry.

(00:46:59):
So you got to have a traffic cop sitting right there in the corner and

(00:47:04):
So now you blow the stop sign.

(00:47:06):
He gives you a ticket.

(00:47:07):
Now you remember,

(00:47:07):
oh,

(00:47:08):
man,

(00:47:08):
I got to make sure I stop at that stop sign because there could be a cop there.

(00:47:11):
He got me last time, right?

(00:47:13):
That's what this is.

(00:47:14):
It's human nature.

(00:47:15):
There has to be accountability.

(00:47:18):
Somebody has to be monitoring this.

(00:47:20):
And the parties have to know that,

(00:47:22):
yeah,

(00:47:22):
they're keeping an eye on me,

(00:47:23):
so I got to make sure I do the right thing here.

(00:47:25):
Unfortunately, it's sad that we have to operate like that, but it is what it is.

(00:47:30):
I had a client...

(00:47:34):
who passed away a few years ago.

(00:47:35):
He was French and spoke with a very, very pronounced French accent.

(00:47:42):
Every year I'd come and do his renewal with him.

(00:47:45):
Every year he would call the insurance companies the greedy bloodsuckers.

(00:47:50):
And I am not vilifying insurance companies.

(00:47:56):
There's so much blame to go around in healthcare that I can call them all that.

(00:48:02):
Everybody's got their fingers in the pie.

(00:48:04):
But I always got a kick out of that every year when.

(00:48:06):
Yeah.

(00:48:07):
And let me clarify, Vinny.

(00:48:10):
I don't I mean,

(00:48:10):
I'm not necessarily of the opinion that we should get rid of them and we should

(00:48:13):
change the entire system.

(00:48:15):
You know, right.

(00:48:16):
Because think about it.

(00:48:17):
You know,

(00:48:17):
these large,

(00:48:18):
especially the large national insurance carriers,

(00:48:20):
they're deeply embedded into the financial system.

(00:48:23):
Absolutely.

(00:48:24):
Institutional hold investors for retirement plan investors,

(00:48:28):
individual investors basically own a piece of these companies.

(00:48:32):
So unless you wanna turn the market upside down, right?

(00:48:36):
You wanna- One-sixth of the economy.

(00:48:37):
I mean, come on.

(00:48:38):
There you go.

(00:48:39):
So you wanna proceed cautiously.

(00:48:41):
Now, that being said,

(00:48:43):
All we're saying is let us see what's going on with our money.

(00:48:47):
Let us see where it's going as the employers.

(00:48:49):
We have a fiduciary, the F word, responsibility to do so.

(00:48:54):
And we just want to make sure that we're paying the amounts that we're supposed to be paying.

(00:48:58):
That's it.

(00:49:00):
And I think it's difficult for anybody,

(00:49:02):
I think,

(00:49:02):
to say,

(00:49:03):
well,

(00:49:03):
you shouldn't have the right to see that.

(00:49:05):
You shouldn't be able to see that information for whatever reason.

(00:49:08):
Yeah.

(00:49:09):
So so just to be clear,

(00:49:11):
you know,

(00:49:11):
I'm not advocating that we eliminate these insurance guys and these national

(00:49:14):
carriers.

(00:49:15):
Right.

(00:49:15):
Right.

(00:49:16):
I'm just saying and I and I actually firmly believe I have confidence myself in the

(00:49:21):
employer community.

(00:49:23):
to police themselves.

(00:49:24):
I think if the employers were able to see everything,

(00:49:27):
I think that would really go a long ways in mitigating this crisis in healthcare,

(00:49:32):
right?

(00:49:33):
I think that's number one.

(00:49:35):
Number two,

(00:49:35):
I also think that based on my experience,

(00:49:38):
maybe some of the folks out there might not agree,

(00:49:40):
but

(00:49:41):
I think most employers do want to do the right thing for their employees.

(00:49:45):
I really do.

(00:49:46):
I think they want to make sure their employees have care and access.

(00:49:49):
And I've had situations where the owners,

(00:49:53):
the principals,

(00:49:53):
the executives were getting cancer treatment.

(00:49:57):
So those guys were invested, obviously.

(00:50:00):
So I think employers,

(00:50:02):
people maybe sometimes shortchange them a little bit,

(00:50:05):
but I think they have the capability to do the right thing,

(00:50:08):
and I think they have the desire to do the right thing.

(00:50:09):
I just think they need the right tools.

(00:50:12):
No, exactly.

(00:50:13):
You're empowering them to take back control of a facet of their health plan that

(00:50:19):
they don't even know they have the ability of taking back.

(00:50:24):
And I think that's the cool bit of what you're doing.

(00:50:26):
So Mark, I appreciate all your time today.

(00:50:31):
What you do is fascinating to me because it's so important to the market to know

(00:50:37):
you're there and there's a resource to go out and find you money that you may not

(00:50:44):
otherwise know you have.

(00:50:46):
So that's cool.

(00:50:48):
So as I mentioned before we started,

(00:50:51):
I have a wine Instagram called Vines with Vinny and always have a good time with it.

(00:50:55):
And I'm always now asking my guests,

(00:50:59):
you know,

(00:51:00):
I'm interested in if they drink wine,

(00:51:02):
do they,

(00:51:02):
do they,

(00:51:02):
what,

(00:51:02):
what they,

(00:51:03):
what are they,

(00:51:03):
what region,

(00:51:04):
what grape,

(00:51:05):
what,

(00:51:05):
what,

(00:51:05):
what,

(00:51:06):
what wine?

(00:51:06):
I mean, do you like wine?

(00:51:09):
I'm actually from California, LA.

(00:51:11):
So we're big wine people here.

(00:51:12):
You know, everybody drinks wine here.

(00:51:14):
I love wine.

(00:51:16):
I would say, you know,

(00:51:19):
I'm partial to Napa,

(00:51:20):
California wine,

(00:51:22):
but I went to Bordeaux with my wife a few years ago,

(00:51:26):
and it was incredible.

(00:51:28):
It was absolutely incredible.

(00:51:30):
I have a newfound appreciation and respect for the French wine and the winemaking process.

(00:51:35):
I love the Pinots from Oregon.

(00:51:37):
I think they're fabulous.

(00:51:39):
I don't know if you've had some of the whites from down south, from Valle de Guadalupe.

(00:51:46):
They're pretty nice, very nice.

(00:51:48):
So the craziest,

(00:51:51):
weirdest place I had wine from here in the States was probably Pittsburgh,

(00:51:54):
Pennsylvania.

(00:51:56):
Wow, I didn't know that.

(00:51:58):
I know they grow grapes.

(00:52:00):
A friend of mine actually just bought 30 acres up in the Finger Lakes region of New York.

(00:52:05):
So he's growing Riesling up there.

(00:52:07):
Yep, they're dry Rieslings, they're beautiful wines.

(00:52:10):
But Pittsburgh,

(00:52:11):
Pennsylvania,

(00:52:11):
I was there for work a few years back and they had a little wine shop and they had

(00:52:15):
local wine.

(00:52:16):
I just thought that was so cool.

(00:52:18):
I thought that was awesome.

(00:52:20):
no let's talk about Bordeaux for a quick second only because earlier this year I

(00:52:24):
got to go to a wine event in New York City which was hosted by this organization of

(00:52:31):
this was 68 Chateau from Bordeaux so I walk into this magnificently large you know

(00:52:38):
event center each each

(00:52:41):
winery had a table.

(00:52:45):
And I made my way through about a third of them and they were presenting the 2022 vintages.

(00:52:52):
And they basically said the 2022 is literally the best Bordeaux vintage you could buy.

(00:52:57):
and so fell in love with some fell in love with some of those went to total wine

(00:53:02):
bought some of those and i did something a few weeks ago that was a little

(00:53:06):
mind-blowing walked into trader joe's i never look at the trader joe's wines

(00:53:10):
walking the trader joe's they have three different 2022 bordeaux's and they're not

(00:53:15):
like grand crew i mean they're they're a little you know they're down the food

(00:53:19):
chain but they were 10 bucks a bottle how bad could they be wow next time you're in

(00:53:24):
trader joe's go find them

(00:53:27):
Are you partial to any of the Appalachians over there in Bordeaux?

(00:53:31):
I'm still learning.

(00:53:32):
I mean, this was my year.

(00:53:34):
I jokingly tell people it was my year of the French because my tastes have been

(00:53:40):
popping all over the place.

(00:53:42):
But France and Bordeaux in particular has been what I've been trying to drink mostly this year.

(00:53:48):
And I'm still getting my palate around the region learning.

(00:53:53):
Well, good for you, Benny.

(00:53:55):
Appreciate that.

(00:53:56):
It's been great talking to you.

(00:53:57):
I'm going to have a glass of wine tonight, actually.

(00:53:59):
No, I hear you.

(00:54:00):
And I appreciate that.

(00:54:01):
So, Mark, thanks again.

(00:54:02):
And we'll talk to you again.

(00:54:05):
Take care.

(00:54:05):
You got it.

(00:54:06):
All right.

(00:54:07):
All right.

(00:54:09):
Bye-bye.

(00:54:10):
This podcast reflects the personal views of the host and guests,

(00:54:14):
not their employers or sponsors.

(00:54:17):
See you next time.