Tag: PBM reform

The “HOME TEAM” Gets Paid 160x MORE. Is That Fair? (Ep. 45)

The “HOME TEAM” Gets Paid 160x MORE. Is That Fair? (Ep. 45)

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In this episode of The Benefit Whisperer, Ralph Weber examines Tennessee’s proposed legislation, SB 2040 and HB 1959, aimed at preventing pharmacy benefit managers (PBMs) from owning pharmacies.

An audit from the Tennessee Department of Commerce & Insurance found instances where a major PBM allegedly reimbursed its own pharmacy up to 16,000% more than independent pharmacies for the same drug. One example cited showed reimbursement of approximately $9,000 versus $57 for identical medication quantities.

Independent pharmacist and healthcare policy advocate Benjamin Jolley explains:

• The structure of SB 2040 and HB 1959
• How these bills mirror Arkansas Act 624
• The economic impact of PBM vertical integration
• What AWP and reimbursement pricing really mean
• Why small employers and self-funded plans could bear the cost
• Legal challenges surrounding similar legislation

This episode explores healthcare market concentration, employer plan costs, and patient access issues through a fact-based policy discussion.

If you’re responsible for healthcare spend, this conversation deserves your attention.

Subscribe for direct, unfiltered conversations exposing waste in healthcare.

🎙 Hosted by Ralph Weber
📌 The Benefit Whisperer

How to Appeal the 850 Million Claims that are Rejected Every Year and Win 70 to 90% of the Time (Ep. 44)

How to Appeal the 850 Million Claims that are Rejected Every Year and Win 70 to 90% of the Time (Ep. 44)

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Healthcare claim denials are not rare administrative errors. They are systemic.

In the United States, approximately 850 million insurance claims are denied every year, roughly 17% of all submitted claims. Yet appeal win rates can range from 70% to 90%, raising a critical question:

Why are so many claims denied in the first place?

In this episode, Ralph Weber speaks with physician and Claimable co-founder Warris Bokhari about:

  • The economics behind insurance claim denials
  • The “98% of eligible claims” narrative, and what it leaves out
  • AI-driven denial systems and automated claim edits
  • Employer liability under ERISA for denied claims
  • Transplant, oncology, and specialty drug denial cases
  • The impact of 200–600 day payment delays on hospitals
  • How patients and employers can respond effectively

They discuss how insurance denials affect patients, employers, providers, and the broader healthcare system, and why appeals succeed at such a high rate when properly constructed.

For employers sponsoring self-funded health plans, this episode is a critical reminder: you are legally responsible for the decisions made on behalf of your plan.

For patients, it offers practical insight into how to push back, and win.

Ralph Weber, The Benefit Whisperer
Share with a colleague. Email ralph@thebenefitwhisperer.com · (832) 924-3330 · fixmybenefitsnow.com · Schedule a free 15 minute consultation

Chris Deacon: $2B Scam Broker Kickbacks & PBM Profits Fiduciary Duties Exposed (Ep. 27)

Chris Deacon: $2B Scam Broker Kickbacks & PBM Profits Fiduciary Duties Exposed (Ep. 27)

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Guest: Chris Deacon, author of The Great American Healthcare Heist and former Director of Health Benefits, State of New Jersey.

Chris joins Ralph Weber to reveal how her team saved $2 billion, including $400M annually on pharmacy spend, by exposing PBM shell games, fixing contracts, and enforcing fiduciary duty.

📌 Topics:

  • How much waste is really in your health plan (30–40%)
  • Reverse auctions and pass-through PBMs explained
  • Why discount guarantees are often a scam
  • Contract terms every plan sponsor should demand

🎧 Listen now to understand how to stop paying for other people’s profits.

📘 Buy the book: The Great American Healthcare Heist

 🔗 Connect with Chris:https://www.linkedin.com/in/cdeaconc/

📬 Questions? ralph@thebenefitwhisperer.com · fixmybenefitsnow.com

Podcast episode thumbnail for The Benefit Whisperer featuring Dr. Don Berwick. Text reads: "The $5 Trillion Lie: Why U.S. Healthcare Fails Us ALL – With Guest Dr. Don Berwick." Includes headshots of Dr. Berwick and host Ralph Weber with Route Three branding and a microphone.
The $5 Trillion Lie: Why U.S. Healthcare Fails Us All With Guest Dr. Don Berwick (Ep. 12)

The $5 Trillion Lie: Why U.S. Healthcare Fails Us All With Guest Dr. Don Berwick (Ep. 12)

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In this powerful episode of The Benefit Whisperer, host Ralph Weber is joined by legendary health policy expert Dr. Donald Berwick, former CMS administrator, Harvard-trained pediatrician, and co-founder of the Institute for Healthcare Improvement, for a candid and urgent conversation about what’s really broken in American healthcare.

Dr. Berwick pulls no punches as he exposes the systemic greed, institutional profiteering, and regulatory loopholes that continue to drive costs up while delivering subpar outcomes. From Medicare Advantage overpayments and PBM manipulation to private equity’s quiet takeover of hospitals and autism care, Berwick breaks down how a system designed to heal has become a $5 trillion machine that transfers wealth from the poor to the rich.

They also discuss the global models that prove a better way is possible, and why American employers, lawmakers, and voters must step up if we want real reform. If you’ve ever felt that our healthcare system isn’t working for you, this episode is essential listening.

Chapters

00:00 Introduction to Healthcare Reform

01:01 Dr. Berwick’s Journey in Healthcare

03:34 The Impact of Profit-Seeking in Healthcare

06:25 Defining Greed in Healthcare

10:27 Healthcare as a Human Right

14:28 The Role of Legislation and Public Activism

18:38 Aligning Incentives with Patient Outcomes

20:57 Employer Responsibility in Healthcare

22:48 Global Perspectives on Healthcare Systems

24:31 Myths About Choice in Healthcare

26:54 Urgent Changes Needed in Congress

28:09 The Role of AI in Healthcare

34:11 Reflections on Leadership Changes in Healthcare