Gott's Gulch - Craig’s Substack Podcast Craig Gottwals

Dive headfirst into the wild world of Reference-Based Pricing, the game-changing strategy that's revolutionizing health plan cost containment like nothing else in the past two decades of employee benefits. Imagine stripping away the cumbersome layers of national carriers and their bloated PPO network fees, paving the way for a bold, new pricing model beyond the tangled web of the Government-Healthcare matrix.
But here's the twist: without a pre-agreed pricing framework between healthcare providers and patients (or their health plans), how do we navigate the murky waters of billing disputes? Picture a scenario where, post-emergency service, a bill is slapped down with a staggering figure—900% above what Medicare might shell out for the same procedure. Sounds like the Wild West, right?
Step into the arena with us as we embark on an exhilarating exploration of the legal intricacies of Reference-Based Pricing, alongside ClaimDOC’s Chief Legal Officer, the formidable Amy Pellegrin. Together, we'll unravel the mysteries of what it means for a repricer to take on the mantle of co-fiduciary for health plans, dissect the legal battles waged by providers against patients and plans, and spotlight the triumphant track record of reference-based repricers in the courtroom.
This is not just a podcast; it's your front-row ticket to the future of healthcare cost management.



This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com

Ever imagine healthcare could feel like the Wild West?  Welcome to the untamed lands of Reference-Based Pricing (RBP), the sizzling frontier where a select few employers unleash radical savings while giving the traditional PPO system a stiff arm.
Unveil a world where only 3-4% of employers dare to tread, but where jaw-dropping 30-40% savings rain like gold and concierge-level service is the sheriff in town.
Curious about RBP's magic? This isn't just healthcare. It's "Health-FAIR!" Here, employers "price-match" medical costs against benchmark prices, slicing their claims in half compared to big insurers. 
Projections say employer healthcare costs will shoot up another 7-9% in 2024. Yet Medicare Part D Premiums are projected to decrease by 1.8%.  All major insurers participate in both markets.  The lesson?  Employers with private insurance are subsidizing Medicare.  But hold your horses. With RBP, brace yourself for a 0-2% trend that turns the tables on traditional care.
Jump into this roller-coaster ride of a podcast with your guide through this maze, joined by two titans of the trade—Omar Arif of ClaimDOC & Scott Schnaidt of HST.  They've both cracked the code, each in their unique ways, and the results? Nothing short of spellbinding.
🎯 What's on Tap:
* The gears and levers behind RBP
* Navigating the legal minefields
* Secrets from Third-Party Administrators (TPAs)
* RBP's performance across the geographical board
* The art of handling balance bill claims
* Litigation: When & How Often
* Co-fiduciaries: The real deal or just smoke and mirrors?
* Show Me the Money: Their pay structure dissected
* Year-end Report Cards: The Good, the Bad, and the Profitable
And just when you think it couldn’t get any cooler—did one of these guys actually play pro baseball in a global tourney, while the other rocked the stage with NIRVANA? 🎸⚾
Lock in your earbuds. Prepare for a mind-bending journey. You’re entering "The Repricers"—Healthcare’s Final Frontier! 🌌🛸



This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com

Yesterday, while live with Joe Getty, a wave of nostalgia swept over me. Together with Jack, we had been at the forefront, passionately deliberating the budding transparency regulations in one of their seminal Extra-Large Podcasts. My memory estimated it to be roughly four years ago.
Digging deep into the archives, I pinpointed the exact date: March 14, 2019. That pivotal conversation laid the bedrock for today's burgeoning free-market revolution. These innovative solutions are now arming both employers and employees with a formidable weapon to shatter a system that's been systematically draining them for far too long.
I invite you to revisit this episode, first broadcast here.



This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com

Your health insurance costs and premiums have skyrocketed compared to the rate of inflation since Obamacare passed. Meanwhile, insurance carrier stock prices have grown by 1900% in the same timeframe.
"They're making unimaginable amounts of money... off of you." -Joe Getty
Craig Gottwals, aka "Craig the Healthcare Guru,” talks about that and more in a new episode of A&G's Extra Large Podcast.
Listen to the Armstrong & Getty Extra Large Podcasts featuring Craig.
Originally posted here: https://www.armstrongandgetty.com/featured/armstrong-and-getty/content/2023-08-08-its-a-government-healthcare-complex-craig-gottwals-talks-to-ag/


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com

Dive into the zany world of tournament bass fishing with Gary Dobyns – a true legend, a visionary entrepreneur, and the mastermind behind Dobyns Rods. Join us on a journey from a humble home bustling with a dozen foster kids in Olivehurst, California, to the glimmering heart of a 30,000-square-foot empire in Sulphur Springs, Texas. Along the way, explore the triumphs of 40 bass boat victories that dot this remarkable life's path.
In this exclusive and intimate conversation, we'll delve deep into the uncharted waters of tournament bass fishing in the West. Discover the art and craft that went into founding Dobyns Rods, the intricate process of building rods in China and Korea, and the fascinating story behind the rise and fall of the Wild West Bass Trail.
Gary's story isn't just about fishing; it's an inspiring American saga. Starting with only a high school education and a job as a $13/hour cable plant worker, Gary embarked on a dazzling 20-year tournament run, averaging two huge wins per year. And then, with a courageous spirit and borderline ambition, he launched Dobyns Rods. Now at the helm of one of the most respected brands in bass fishing, Gary's story continues to unfold.
Don't miss this opportunity to reel in wisdom, passion, and insight from a man who has conquered not only the waters but also the business world. Whether you're an avid angler or simply seeking a tale of determination and success, this podcast is a catch you won't want to miss.


This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit gottwals.substack.com

The labyrinthine American health insurance system, while ostensibly designed to safeguard our health care dollars, is rife with the specter of fraud, a malaise that stealthily siphons off staggering amounts of money. More than $1 trillion — one of every three dollars that passes through the health care system — is lost to fraud, wasted on services that don’t help patients, or otherwise misspent.
With private insurance spending soaring to $1.2 trillion in 2019, it's disconcerting that there's no systematic tracking of funds lost to fraud. Investigators and experts speculate that up to 10% of all healthcare spending may be devoured solely by fraudulent schemes. While insurance companies assure the public of their vigilance in monitoring and protecting these funds, the stark reality is alarmingly different: fraudsters find easy access to this system, and convincing insurance companies to shut them down is an uphill battle.
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One egregious example reported in Marshall Allen’s fantastic book, “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win,” is the case of David Williams. Williams, a personal trainer who exploited vulnerabilities in the healthcare payment system to bilk millions from private insurers and employers. Williams, without any valid credentials, applied for a National Provider Identifier number (NPI), a requisite for medical providers to bill insurance plans, and was handed one with no verification. Equipped with this, he embarked on a fraudulent scheme, billing insurers for workout sessions under the guise of medical services. His victims included not only UnitedHealthcare but also Aetna and Cigna, with Southwest Airlines being the hardest hit through its self-funded benefits plan. By the time he was apprehended, Williams had successfully defrauded these companies for over four years, amassing about $4 million in cash from $25 million in fraudulent billing.
This staggering case elucidates a stark reality: health insurers are woefully inadequate in protecting your healthcare dollars. Fraud like this thrives due to a lack of vigilance and urgency on the part of insurers, who often fail to validate the credentials of those submitting claims. Williams, for instance, was able to submit claims and receive payments, despite complaints and warnings about his fraudulent activities. His exploitation of the system was not an act of a criminal mastermind but rather a demonstration of the system's vulnerabilities and the insurance companies' laxity.
When it comes to dealing with fraud, insurance companies often adopt a passive stance, primarily for two reasons.  First, as it relates to self-funded plans, prosecuting fraud cases is costly and challenging. In many cases, the approach is to settle or block suspicious providers rather than pursue costly legal proceedings. This practice raises serious doubts about the commitment of these corporations to stamp out fraud.
Secondly, as it relates to fully insured plans, insurance companies are disincentivized to uncover fraud, waste, or abuse. The Patient Protection and Affordable Care Act (Obamacare) unintentionally created an environment where health insurance carriers have a reduced motivation to vigilantly monitor and control waste, fraud, and abuse. This is due to the mandatory minimum Medical Loss Ratio (MLR) rule, which stipulates that insurance carriers must spend at least 85% of premiums on actual health claims, leaving a maximum of 15% for administrative costs, marketing, and profit.
In theory, this regulation was designed to ensure that a substantial proportion of premiums go towards actual healthcare services. However, it also inadvertently created a scenario where carriers might benefit from higher claims.
If the total claims increase, the 15% that carriers are allowed to keep also increases in absolute terms. For in