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TABLE OF CONTENTS
Market Trends, Studies, Books & Opinions Legal, Legislative & Regulatory News
Editorial Notes, Disclaimers & Disclosures The Phia Group and AMPS Comment on CNN Report On Outrageous Hospital Charges
MyHealthGuide Source: AMPS and The Phia Group, 3/9/2010,
www.advancedpricing.com
and
www.phiagroup.com Atlanta, GA -- CNN aired a report by reporter Elizabeth Cohen on inappropriate charges by hospitals for various items used for patient care. Among the examples cited were a single toothbrush billed at $1,000 and a single Tylenol caplet billed for $140. The report details how these are not isolated incidents, but rather part of how hospitals regularly bill patients and insurance companies. Mike Dendy of AMPS and Adam Russo of Phia have responded to this report. "Egregious charges like those described in the CNN report are much less of an anomaly than most payers think," commented Mike Dendy, President and CEO of Advanced Medical Pricing Solutions. "Our observation is that perhaps the hospital that charged for 41 bags of solution (but only used 1) may be expecting payment in full because the charge was for an in-network service where they had a contract that calls for payment without an external audit," added Adam Russo, CEO and Founder of Phia. "This and thousands of other examples we have in our data base provide a clear sign that smaller payers that use rental PPO networks need to consider alternatives to the PPO model and move on to other forms of cost containment," continued Dendy. Russo stated that, "Many self-funded employee benefit plans have language in their plan documents that specifically allow for claims to be audited and paid on usual, reasonable, and customary terms, but most PPOs do not allow for this to occur. If these benefit plans follow the terms of the plan document, in many cases an audit of itemized charges will violate the terms of the PPO agreement and our industry needs to do something about this."
A Wall Street Journal article published on January 30th reported
that Hospital Corporation of America (HCA) paid out a $1.75 billion dividend to
their investors for 2009 results. The Journal notes the payout to be among the biggest ever.
About AMPS Founded in 1995, AMPS now has offices in Atlanta, GA; Chattanooga , TN; and Phoenix, AR. AMPS' reviews have yielded an average cost savings on adjusted hospital claims of 20.55% (over and above PPO discounts). With an average size of claim reviewed of $51,365, this has yielded an average additional dollar reduction of $10,986 per claim. AMPS average success (hit) rate on claims greater than $15,000 reviewed is 90.5%. Call Jim Delaney, COO, at 678-528-3041 and visit www.advancedpricing.com. About The Phia Group The Phia Group, headquartered in Braintree, MA, represents third party administrators, self-insured companies, insurance carriers, reinsurers, and other at-risk entities across the country. The company's services include subrogation, claim reimbursement, overpayment recovery and coordination of benefits. The Phia Group has become one of the fastest growing subrogation companies in the nation. Call 888-986-0080 and visit www.phiagroup.com. MasterBrand Cabinets Selects Bravo Wellness to Manage Wellness Initiatives MyHealthGuide Source: Bravo Wellness, 3/11/2010, www.BravoWell.com CLEVELAND, OH -- Bravo Wellness, a provider of results-based incentives for wellness, announced that MasterBrand Cabinets, Inc., its 50th customer, selected Bravo Wellness to implement its wellness initiatives for its 5,700 US employees. "Traditional wellness programs just do not work because they are not tied to results," states Robert Jacobs, Executive Vice President of Human Resources at MasterBrand Cabinets. "Results from other wellness initiatives that Bravo has done cannot be ignored, and results- based wellness programs like Bravo's need to be a critical component of a national health strategy." "We routinely see over 97% of those eligible participate in the wellness assessment," says Jim Pshock, Founder and President of Bravo Wellness. "Bravo's plans are typically designed to incent participants who choose healthy lifestyle behaviors and increase costs for those who do not. Accommodations are made for individuals with medical issues that might make a typical healthy lifestyle goal unreasonable. Tying employee costs to their healthy choices is a real motivator and actually works." MasterBrand Cabinets represents the 50th company to select Bravo Wellness to manage its results-based wellness initiative since its inception in 2008. Bravo Wellness' compliance expertise and state-of-the-art technology enables organizations to find all of the support they need to move beyond wellness participation goals to outcome based programs, whether incentives or penalties are employed. Most of Bravo's clients have experienced a 97% participation and significant return on investment in the first year. Bravo Wellness provides consulting, administrative support for the appeal/reasonable alternative process and custom programming to convert results into a payroll or eligibility file. If needed, Bravo Wellness can also arrange biometric screenings, health risk assessments and health coaching through strategic partners. About Bravo Wellness Bravo Wellness offers services to employers and business partners desiring results-based incentives for wellness. Customers experience immediate cost savings by linking employee incentives to participation and results. Bravo Wellness recognized the potential legal challenges of health insurance law, including HIPAA non-discrimination regulations, and has unique expertise in the practical application of wellness regulations for group health plans. Bravo Wellness is headquartered in Avon, Ohio. Contact Jim Pshock at (440) 934-2090, jimpshock@bravowell.com and visit www.BravoWell.com OptumHealth Acquires Wellness Inc. MyHealthGuide Source: TripleTree, 3/10/2010, www.triple-tree.com Minneapolis, MN -- TripleTree is pleased to announce that its client, Wellness Inc., a leading worksite wellness company that provides health services through more than 1,000 employers nationwide, was acquired by OptumHealth, a UnitedHealth Group (NYSE: UNH) company. OptumHealth will expand its wellness programs to include Wellness Inc.'s innovative solutions, including worksite-based biometric screenings that help to identify risk factors and detect disease in early stages. TripleTree, LLC acted as the exclusive financial advisor to Wellness, Inc. With Wellness Inc., OptumHealth broadens its support for those employers who want more comprehensive and convenient ways to help employees proactively manage their health. Wellness Inc. brings to OptumHealth its biometric screenings -- utilizing a blood panel of 36 medical tests to detect disease --seasonal and H1N1 flu vaccination services and interactive health assessments delivered on-site, which helps to identify lifestyle-related health risks. In addition, Wellness Inc. provides employers with a comprehensive view of the health of their population over time and individual participants with detailed and confidential personal health information. "For 24 years, our mission has been to engage and educate individuals on their current health status, while providing customized roadmaps for achieving a healthier lifestyle in the future," said Gary Fine, CEO of Wellness Inc. "The complement of solutions and services between OptumHealth and Wellness Inc. will give our customers and their employees best-in-class options for creating a culture of health within their organizations." Peter Erickson, Managing Director at TripleTree said, "Wellness Inc.'s unique ability to offer comprehensive laboratory screenings on a national basis is a clear value driver to employers seeking to understand the health of all of its health plan members. This front-end biometric and health assessment data is critical to plan, optimize, and evaluate the performance of other population health management initiatives sponsored by employers. With this acquisition, OptumHealth has added best-of-breed screening services that will be integrated with its comprehensive offering of health management programs." "TripleTree was an invaluable advisor that guided Wellness Inc. and was deeply involved in every step leading up this important event for our company," said Gary Fine. "As the sole owner of the business in my first sale process, I was very concerned about exposing confidential information to potential acquirers." About TripleTree TripleTree provides mid-market healthcare and technology businesses and their financial sponsors with specialized investment banking support, including merger and acquisition advisory, private capital, and principal investing services. Call (952) 253-5300 and visit www.triple-tree.com. New HighRoads Benefit Financial Management Service Offers Self-funded Employers Better Forecast Claims Tool MyHealthGuide Source: HighRoads, 3/11/2010, www.HighRoads.com
BOSTON -- Human capital costs -- health benefits claims included
-- are of enormous significance to a company's financial health, but until now there
was no efficient, cost effective way for self-funded companies to
analyze and predict
claims costs. HighRoads, an industry leader in employer health care database and
benefits management, today launches the solution: the HighRoads Benefit Financial
Management Service delivered through HighRoads Health and Welfare Consulting Group.
Managers can:
Employers gain real-time insights into program finances and, if desired,
can receive summary level reports with commentary from HighRoads Health and Welfare
Consulting Group. The reports can put the data into further context, identifying
demographic and claims drivers, budget expectations, claims cost trends, and spotting
any cost anomalies and recommending future strategy.
CHT Releases Version 4.0 of BenefitSpan™ With Integrated HSA, FSA and HRA Consumer Portal and Rich User Experience MyHealthGuide Source: Consumer Health Technologies, Inc. (CHT), 3/9/2010, www.consumerhealthtech.com
Ft. Lauderdale, FL -- Consumer Health Technologies, Inc. (CHT), the
Consumer Directed Healthcare (CDHC) software company that provides total benefits
administration and service aggregation solutions to administrators, payers, and
financial institutions has released version 4.0 of its award-winning BenefitSpan™
platform featuring an integrated account access portal and a streamlined user experience
for all CDHC accounts and services. Consumer Health Technologies, Inc. enables third-party administrators (TPA), banks and payers to rapidly assemble, price, deliver and administer consumer-centric health benefit accounts and services via BenefitSpan™, the total CDHC service platform. BenefitSpan™ supports rapid integration and delivery of healthcare transactions, financial services and a wide array of supporting services such as HealthMall cash back reward program, wellness programs, telemedicine, healthcare advocacy and much more. These services can be assembled, personalized and delivered in a targeted fashion to meet the needs of the individual and group clients for benefit accounts, consumer health services delivery and administrative solutions. Payers and administrators can also manage the consumer and provider revenue cycles with CHT's BillSpan™ product, a total payment administration and revenue cycle management solution that delivers comprehensive healthcare payments and revenue management capabilities. Contact Kelly Gregorakis, Director of Marketing, at 954-315-0902, Kelly.Gregorakis@consumerhealthtech.com and visit www.consumerhealthtech.com. MagnaCare Expands Member-Centric Programs and Services Built Through Customer Satisfaction MyHealthGuide Source: MagnaCare, 3/9/2010, www.magnacare.com NEW YORK, NY -- MagnaCare, a health plan services company with national reach, announces plans to build on its stable customer base and dominant position in the fiercely competitive NY/NJ/CT region to expand into the broader health care services market. Pointing to innovative differentiators fueling continued growth and expanded market share, MagnaCare cites its ability to provide exemplary customer service and offer deep discounts to Taft-Hartley funds, self-insured companies, commercial insurers for health, workers' compensation, or no fault, Third Party Administrators (TPAs), and government entities.
"With 20 years of vigorous organic growth, MagnaCare serves a diverse customer base and maintains long-standing relationships, with our top 20 customers
averaging nearly 10+ years," says Joseph Berardo, Jr., president and CEO
of MagnaCare. "We've demonstrated high retention rates -- averaging 95% historically,
positive pricing trends, and historical investments in infrastructure support. This
stellar market position is reflected in a solid financial profile with overall compound
annual growth rate (CAGR) of over 12%.
EvaluaideSM product, a sophisticated
program that offers the best in predictive modeling combined with individualized
coaching and outreach.
Additionally, MagnaCareRx, the company's Pharmacy Benefit Manager
(PBM), effectively addresses the pharmaceutical spend with a transparent business
model that meets the fiscal needs of employers and payers.
MagnaCare is a health plan services company that touches millions of lives nationwide. For over 20 years, MagnaCare has provided solutions to Taft-Hartley funds, self insured companies, commercial insurers such as health, workers compensation, or no fault, TPA's, and government entities. Whether it's access to a broad provider network, predictive modeling analyses, member outreach programs or an integrated solution that includes full plan management services including claims adjudication, eligibility management, client/customer service, MagnaCare understands its customers' needs and develops cost effective, comprehensive solutions. Visit www.magnacare.com and www.facebook.com/magnacare. HCAA's 2010 Executive Forum Achieves Record Attendance MyHealthGuide Source: The Health Care Administrators Association (HCAA) , 3/8/2010, www.HCAA.org Minneapolis, MN -- Over 270 leaders from the self funded health insurance industry attended the Health Care Administrators Association's (HCAA) Executive Forum at Encore at Wynn Las Vegas on February 9 -- 11, 2010. The conference, "Effective Leadership in a Time of Change," focused on navigating the turbulent economy and ensuring a company's viability in unpredictable times. Attendees heard from numerous speakers including Dr. JP Pawliw-Fry, keynote speaker on Wednesday, February 10 and Rich Horwath, keynote speaker on Thursday, February 11. Presentations shared information on leveraging business diversification, aligning products and services with reform initiatives and employing other strategies which will position attendees companies in a position to capitalize on opportunities to change. HCAA welcomed MyHealthGuide, LCC and Care Here, LLC President, Ernie Clevenger as conference facilitator. Clevenger shared his knowledge of industry trends and various reform initiatives, along with his professional insights. Attendance at the 2010 Executive Forum marks the largest conference for HCAA to date. "HCAA celebrates 30 years as an association this year [2010]. Having our largest conference yet is a great way to being the celebration," said Executive Director, Jaime Nolan, CAE. "Attendance at our conferences continues to grow each year. We're looking forward to breaking another attendance record at TPA University in July," continues Nolan. TPA University is July 21 -- 23 at the Westin Tabor Center in Denver, Colorado. More details are available on the HCAA Web site at www.hcaa.org. About HCAA The Health Care Administrators Association (HCAA) is a nonprofit trade association comprised of third party administrators (TPAs), insurance carriers, managing general underwriters, audit firms, physician hospital organizations, brokers/agents, human resource managers and health care consultants. Visit www.hcaa.org. GPA Names J.W. Dewbre as Vice President MyHealthGuide Source: Group & Pension Administrators, Inc., (GPA), 2/24/2010, www.gpatpa.com
Dallas, TX -- Group & Pension Administrators, Inc., (GPA) one
of the largest third-party benefit administrators in the Southwestern United
States, today announced that its General Counsel, J.W. Dewbre, has been named Vice
President. In his new role, Mr. Dewbre will help drive the strategic direction of
GPA while continuing to oversee the legal affairs of the company. He has been chief
counsel at GPA since August 2007. Group & Pension Administrators, Inc. (GPA) is the largest independently owned third-party administrator (TPA) in the Southwest, providing highest-quality and custom healthcare benefit management solutions to self-insured employers. For 42 years, GPA has combined its value of service excellence with a commitment to clients, employing industry-leading technology, tools and -- above all -- "high-touch" patient care to deliver the healthiest employees and the "healthiest" bottom line. GPA clients, including The Container Store and The SCOOTER Store who were named to FORTUNE magazine's list of "100 Best Companies to Work For," are recognized for being discerning employers that demand the highest quality benefits at the best price for their employees. Visit www.gpatpa.com. PHX Adds Lindsay DeYoung as Vice President of Payor Sales MyHealthGuide Source: PHX, 3/8/2010, www.phx-online.com
Bedminster, NJ -- PHX, a leader in healthcare cost management, is
pleased to welcome Lindsay DeYoung as Vice President of Payor Sales. PHX delivers advanced cost management solutions for health plans. The company combines claim processing automation with professional services to deliver a centralized approach to cost management, increasing savings in both the near and long term while dramatically reducing errors and turnaround time. The firm's solutions are used by a number of the industry's leading insurance companies, Health Maintenance Organizations (HMOs), and Third Party Administrators (TPAs). PHX services include claims editing, clinical bill review and audit, proprietary and secondary network repricing, fee negotiations, fraud and abuse detection, and health benefits trend analysis and reporting. All services are handled in-house for maximum privacy and legal and regulatory compliance. PHX also supplies full technology implementation, training and support for quick, seamless integration into any organization. Visit www.phx-online.com. Total Medical Solutions Expands Sales Team with Frank Fredryk As National Account Manager and Stan Boystov As Regional Account Manager MyHealthGuide Source: Total Medical Solutions, 3/5/2010, www.newtms.com ORLANDO, FL -- Total Medical Solutions (TMS) has promoted Frank Fredryk to national account manager and appointed Stan Boystov to regional account manager.
Frank J. Fredryk, National Account Manager
Stan Boystov, Regional Account Manager TriZetto Appoints Jeffrey Rideout, M.D. as Senior Vice President, Care and Cost Management, and Chief Medical Officer MyHealthGuide Source: The TriZetto Group, Inc., 3/10/2010, www.TriZetto.com
NEWPORT BEACH, CA -- The TriZetto Group, Inc. announced the appointment
of Jeffrey Rideout, M.D., as senior vice president, care and cost management
and as chief medical officer. Dr. Rideout will lead the systematic expansion of
TriZetto's cost and quality of care solutions sets, including value-based benefits,
value-based reimbursement and pharmacy utilization management, to help the company's
payer customers drive greater value in care for members and providers.
NBGH Honors IBM Executive, Dr. Martín Sepúlveda, with Excellence and Innovation in Value Purchasing Award MyHealthGuide Source: The National Business Group on Health (NBGH), 3/11/2010, www.businessgrouphealth.org
Washington, DC -- The National Business Group on Health, a non-profit
group of more than 280 large U.S. employers, today awarded its 8th Annual Award
for Excellence and Innovation in Value Purchasing to Martín Sepúlveda, MD, FACP,
IBM Fellow and Vice President of Integrated Health
Services. The award, which recognizes
Dr. Sepúlveda for his leadership and commitment to employee health, productivity
and overall well-being, was presented at the Business Group's annual Health Agenda
Conference held in Washington, DC.
About the National Business Group on Health URAC Names Dr. Robert Honigberg Chief Medical Officer MyHealthGuide Source: URAC, 3/08/2010, www.URAC.org Washington, DC -- URAC, the nation's leading health care accreditation and education organization, announced the appointment of Robert M. Honigberg, M.D., M.B.A, as Chief Medical Officer. In his role, Dr. Honigberg will advise on quality measurement and clinical effectiveness research and will lead global wellness and health promotion initiatives for URAC.
"We are pleased to have Robert as part of the URAC team. His in-depth
knowledge of pharmaceutical research, medical technology, patient safety and medical
communication will be invaluable as URAC continues to innovate and expand in the
rapidly changing health care environment," said Alan P. Spielman, president
and CEO of URAC. "We have a long history of leveraging the best minds in the industry
through our many accreditation committees and partnerships. It is exciting to have
Robert continue that tradition for URAC." URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation, education and measurement programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. Visit www.urac.org. Market Trends, Studies, Books & Opinions
Firms With 50 to 500
Employees Turning to Captives
Article referred by
John H.
Eggertsen, (734) 794-7100, Eggertsen Consulting, P.C. "This is the newest frontier," said George O'Donnell, a senior vp with Aon Consulting in Somerset, N.J. "The potential here is huge," said Dick Goff, a managing member with captive manager Taft Cos. L.L.C. in Towson, Md. Smaller employers' health care benefits captive funding is taking a variety of directions. In some cases, small employers, with the help of third-party claims administrators or benefit consultants, are joining forces to set up their own captives or using a cell in an established captive to cover risk above a self-insured retention. In other cases, small- and medium-size employers--typically defined as firms with between 50 and 500 employees--are securing coverage in captives owned by TPAs or trade associations to which they belong. "A variety of models are being used," said Karin Landry, a managing principal with Spring Consulting L.L.C. in Boston. Regardless of the approach, small employers banding together to fund health care benefits risks are so doing with the singular purpose of saving money. By boosting retentions and pooling risks in captives with other employers--who typically agree to put in wellness, disease management and other programs to lower claims costs--small employers hope to keep increases in health insurance costs more in check. "Captives can be an excellent solution" to slow increases in costs, Ms. Landry said. In addition, by pooling their risks in a captive program, participating small employers can hold on to profits--if premiums they pay exceed claims and other costs--rather than surrendering profits to a commercial insurer, as would be the case in a fully insured program. "We can save employers money by eliminating carrier profits," said Gary Becker, president of Becker Benefit Group Inc. an Owings Mills, Md.-based insurance agency and consultant that works with small and midsize employers on group health care captive approaches. Some of the programs are relatively new. For example, Avizent Alternative Risk, a unit of Avizent, a Columbus, Ohio-based TPA and risk management service provider, launched a program last month that provides coverage above a minimum $25,000 self-insured retention to employers with at least 50 employees. Coverage is offered through a cell that is part of a Bermuda captive, Atlantic Gateway International Ltd., which Avizent owns. By year-end, "we'd like to have 1,000 lives covered through the program," said Rick Stasi, chief operating officer for Avizent Alternative Risk in Lexington, Ky. Other programs are expanding. For example, Vermont-domiciled SystemsPlus Mutual Insurance Co. was launched last year as an association captive to provide coverage to the small-business membership base of the Cedar Rapids, Iowa-based National Systems Contactors Assn. Then in January, the captive was redesigned into a sponsored segregated cell captive. In that arrangement, other trade organizations and industry groups can utilize cells to provide coverage to participating members, said Tim Johnson, CEO of Benefit Captive Re in Norwalk, Iowa, which is the captive's program manager. The newest cell participants are members of the Oak Brook, Ill.-based Associated Equipment Distributors Inc.
MyHealthGuide Source: Ronald E. Bachman, FSA, MAAA,
is President and CEO, Healthcare Visions, Inc. and a senior fellow with the National
Center for Policy Analysis, 3/5/2010,
NCPA Article
For example, the health care bill passed by the Senate (December
24, 2009) does not directly outlaw HSA-eligible plans, but it restricts HSA options
in insidious ways that will delay, deny, defeat and ultimately kill them.
HSA health plans are insurance plans that allow an individual and/or
his employer to deposit funds into a special savings account. The funds are not
subject to the income tax if withdrawals are used to pay out-of-pocket medical expenses.
Right now, HSA plans are the only form of health insurance under which an individual's
out-of-pocket exposure is limited by law. Currently, the limits are $5,950 for individuals
and $11,900 for families. A plan could have lower deductibles and require patient
copays up the total limit, or it could have deductibles as high as $5,950/$11,900
so long as the plan pays all costs above those amounts.
By empowering individuals, emphasizing personal responsibility, and
encouraging more effective use of health care services, consumer-driven health plans
have been shown to lower overall health costs more than managed care plans, such
as Preferred Provider Organizations (PPOs). According to an American Academy of
Actuaries study: "The total savings generated could be as much as 12% to 20% in
the first year. After the first year, studies indicate trend rates lower than traditional
PPO plans by approximately 3% to 5%." Yet, Congress has ignored the data and is
set to limit the ability of the private sector to take advantage of these proven
cost-control options.
Under the Senate proposal, a 40% excise tax would apply to any health
plan premiums exceeding $8,500 per individual. An individual who put the maximum
$3,050 into an HSA would have only $5,450 to purchase medical insurance, dental coverage, vision and all other federally-mandated health benefits. For individuals
age 55 years or more, the maximum HSA deposit is currently $4,050. That leaves only
$4,450 for health premiums before a 40% excise tax would apply.
The Senate bill lists broad categories of health care without any
specifics on treatments covered or financial limits that may apply. It says that
the Secretary of Health and Human Services (HHS) "shall define the essential health
benefits" that all individuals will be required to obtain and ensure that the coverage
is "equal to the benefits provided under a typical employer plan." Since new HSA
plan designs and concepts are by definition not "typical," new-generation HSAs will
likely be restricted. An approach that allows only a narrow range of "typical" products
will stifle creative solutions.
Many in Congress oppose HSA plans and consider them "under-insurance."
They believe, contrary to evidence, that HSAs are only for the young, healthy and
wealthy. With broad powers, the Secretary could easily outlaw HSA plans by defining
essential health benefits to include coverage that would violate HSA eligibility
under federal law.
The Senate bill would not allow HSA funds to be used to purchase
most over-the-counter (OTC) drugs. This will greatly hamper the incentive HSAs give
people to control drug costs. For example, as a prescription drug, Claritin costs
about $2.50 a day. The OTC price immediately dropped to $1 a day and it is now about
50 cents. By prescription, the heartburn drug Prilosec costs about $4 a day. It
is now available OTC for as little as 50 cents a day. Obviously, it makes no sense
to prohibit patients from making these kinds of lower-cost choices.
The Senate bill would increase the penalty for disallowed HSA withdrawals
from 10% to 20%. Other restrictions may also be included in the final bill. For
example, one proposal would require expensive third-party adjudication of HSA withdrawals
to "prove" the expenditures were for medical care. Other (possible) proposals would
limit the annual dollar amount that can be contributed to HSAs. Restricting HSAs
is a process likely to continue as the reform debate winds forward.
New consumer-driven plans include financial rewards and incentives
for healthy behaviors. The Senate proposal specifically outlaws using health status
to determine premium rates. On a positive note, if a recognized "wellness program"
is in place, some rewards other than premium discounts are allowed. However, letting
an insurer or employer put dollars directly into an HSA account is not on the list
of rewards that are allowed.
HSA plans allow younger adults to purchase catastrophic protection
for premiums that are 30% to 40% lower than traditional insurance. Studies have
shown that 30% or more of those purchasing HSA-eligible plans were previously uninsured.
Actuarially, young adult claims are about 20% of older adults. But, the Senate bill
would require premiums for young adults that are no less than 33% of the premiums
charged to older adults. This will raise the cost of single and family premiums
by 50% to 100% or more. Artificial government price controls will deny equitable
risk pricing and defeat efforts to lower the number of uninsured.
The proposed Senate health reform bill is designed to delay, deny, defeat and kill HSAs. It does not focus on improving health or health care. It is more about political power, centralizing federal control, growing government and expanding bureaucracies. About NCPA
The National Center for Policy Analysis (NCPA) is a nonprofit, nonpartisan
public policy research organization, established in 1983. The NCPA's goal
is to develop and promote private alternatives to government regulation and control,
solving problems by relying on the strength of the competitive, entrepreneurial private sector. Topics include reforms in health care, taxes, Social Security, welfare,
criminal justice, education and environmental regulation. Visit
www.NCPA.org.
Legal, Legislative & Regulatory News SIIA Welcomes Legislation to Modernize Federal Regulation of Risk Retention Groups (RRG) MyHealthGuide Source: The Self-Insurance Institute of America, Inc. (SIIA), 3/10/2010, www.SIIA.org
WASHINGTON, DC -- The Self-Insurance Institute of America, Inc. (SIIA)
welcomed the introduction in Congress of "The Risk Retention Modernization Act"
About SIIA Stop Loss Provider, United Re Ag, Files for Bankruptcy MyHealthGuide Source:
On February 12, 2010, United Re Ag filed for Chapter 11 bankruptcy. While the company's website ( www.united-re.com ) cannot be accessed currently, the following information was retrieved using the Google cache feature:
The Bankruptcy Petition shows creditors as Boys & Girls Club, D.W. Dickey & Son Inc. and several others. United Re Cited in Past Newsletter Article Separate from the Petition, but related to United Re Ag and D.W. Dickey, in the February 1, 2010 edition of this Newsletter, an article written by Meredith Z. Maresca, writer for BNA's Pension & Benefits Daily, reported that a District Court in Ohio ruled that the TPA was the proper defendent in the ERISA Case (Nationwide Children's Hospital Inc. v. D.W. Dickey & Son, Inc. Employee Health and Welfare Plan, S.D. Ohio, No. 2:08-cv-1140, 1/27/10. Court's Opinion). The case is summarized below. The Nationwide Children's case stemmed from the denial of benefits for treatment that a D.W. Dickey & Son Inc. Employee Health and Welfare Plan participant's minor son underwent to treat an aggressive form of bone cancer, known as Ewing's Sarcoma. Dickey sponsored and administrated the plan, and The Masters Agency Inc., which did business as American Benefits Management, was the plan's third-party administrator. United Re AG reinsured the plan. Health care providers, as assignees of the participant's rights under the plan, sued after United Re determined that treatment the beneficiary underwent as part of a children's cancer study was barred under a plan exclusion for "experimental and/or investigational" treatments. As part of the study, the beneficiary utilized two drug therapies in addition to undergoing standard chemotherapy. Following United Re's decision, American Benefits notified the providers that already-approved and paid claims were not payable, and sought reimbursement. United Re declined to change its position on administrative appeal, even though multiple doctors opined that the treatment was not experimental and should have been covered. In the lawsuit against Dickey, the plan, and American Benefits, the providers sought benefits under ERISA Section 502(a)(1)(B). In addition, the participant filed a counterclaim alleging that the plan, through American Benefits, wrongly denied over $684,623 in valid medical claims. He brought a benefit claim under ERISA Section 502(a)(1)(B) and two claims under ERISA Section 502(a)(3) for breach of fiduciary duty. In a previous decision issued days before the current decision, the court denied a motion to dismiss by Dickey and the plan regarding the participant's counterclaims. The court said the participant could continue with his lawsuit for coverage for his son's treatment, finding that the motion was premature at that time. The court concluded that the plan was not the only proper defendant in a Section 502(a)(1)(B) action to recover benefits, the court said the "essential rationale" was whether the defendant had control over the administration of the plan. The pleading at issue did not "foreclose" that American Benefits controlled the administration of the plan or was a fiduciary, the court said. Although the court declined to dismiss the Section 502(a)(1)(B) claim against American Benefits, it noted that the evidence could ultimately demonstrate that American Benefits did not interpret the plan's definition of "experimental and investigational" treatment and did not deny the benefit claims.
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Many Angiograms Are Not Needed MyHealthGuide Source: The New England Journal of Medicine, Volume 362:886-895, No 10, 3/10/2010, NEJM Abstract Many patients who have an angiogram have no significant heart disease according to a study published in The New England Journal of Medicine. Researchers suggests that doctors need better ways to decide who should have the test. The study included 398,978 patients with an average age of 61 between January 2004 and April 2008. 52.7% of the patients were men, 26.0% had diabetes, and 69.6% had hypertension. The patients' demographic characteristics, risk factors, and symptoms and the results of noninvasive testing were correlated with the presence of obstructive coronary artery disease, which was defined as stenosis of 50% or more of the diameter of the left main coronary artery or stenosis of 70% or more of the diameter of a major epicardial vessel. Study findings
Researchers concluded that slightly more than one third of patients without known disease who underwent elective cardiac catheterization had obstructive coronary artery disease. Better strategies for risk stratification are needed to inform decisions and to increase the diagnostic yield of cardiac catheterization in routine clinical practice. Standard Stop-Loss Employer Disclosure Form Endorsed MyHealthGuide Source: Self-Insurance Institute of America (SIIA, www.SIIA.org), Society of Professional Benefit Administrators (SPBA, www.SPBATPA.org), Recurring article Self-Insurance Institute of America ( www.SIIA.org ) and Society of Professional Benefit Administrators ( www.SPBATPA.org ) have endorsed a standardized stop-loss disclosure form, which also includes ICD-9 codes. The documents are intended to help facilitate the sharing of health data information between self-insured entities/TPAs and stop-loss insurers/MGUs for the purpose of medical stop-loss underwriting. Stop-Loss Carriers and MGUs Adopt the Standardized Form The list below represents an estimated $3.3 Billion in Stop-Loss premium. Assuming a medical self-funded community Stop-Loss market of $4 Billion, then over 80% of the market has adopted the form. If you are a Stop-Loss carrier or MGU that has adopted the standard disclosure form, please let us know at Info@MyHealthGuide.com.
Latest Survey Results Recommending Adoption Respondents from the self-funded community have voted 86% in favor of adoption of the standard form for Stop-Loss disclosure. For all survey results, see www.MyHealthGuide.com/disclosures.htm. Standard Form Adoption May Not Mean Standardization While surveyed members (n=112) from the self-funded community voted 86% in favor of adoption of the standard form for Stop-Loss disclosure and a majority of the Stop-Loss market has adopted the form, complete standardization is still a goal. LaRea Albert of Health First TPA (Tyler, TX ) complains, "The Standard Stop-Loss Employer Disclosure Form is not standard, we are getting a different standard from various MGUs and carriers." Another colleague at Health First, said, "Each Stop-Loss source requires enough 'extras' that Health First concludes the form should not be called, "Standard."
"These comments show that, at least down at the operating level, many underwriters and their managers 'do not get it'!
If the form is 'approved', but insist on the unique information carrier by carrier, then that's not accepting the standard, " says John Lord, Vice President-Specialty Zurich Specialty Health, and a member of the Industry Study Group which developed the Standard Disclosure
Form. "Clearly we have work to do to get the message out to all the right people." The following draft documents may be downloaded and viewed at www.myhealthguide.com/disclosures.htm.
About Employer Disclosure The Employer Disclosure, required by most Stop-Loss carriers and MGUs, has grown in sophistication and use. Today, most Stop-Loss sources require an employer disclosure before a new or renewal quote is offered. Ideally, the Employer Disclosure lists all known high cost claims, claims that have exceed a given dollar threshold, or patient/employees with certain diagnoses. Failure to disclose these individuals can later lead to claim denials. For the past several years, an industry study group has worked on "standardizing" the reporting process with the objective that all insurers would come to accept the reporting system/form as an industry standard.
March 26, 2010
April 6-8, 2010
April 12-13, 2010
April 13-15, 2010
April 14-16, 2010
April 25-28, 2010
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April 26-28, 2010
April 26-28, 2010
May 10-11, 2010
May 11-13, 2010
May 12-14, 2010
May 17-20, 2010
June 7-9, 2010
June 7-9, 2010 AHIP's Institute 2010 presented by America's Health Insurance Plans. Keynotes, workshop, concurrent, and breakfast sessions; plenty of networking; and an exhibit hall with nearly 200 companies. Las Vegas, NV. Contact Erin Ross, MS, Deputy Director, Marketing, America's Health Insurance Plans at 202.778.3294. Information and registration: www.ahip.org/links/institute2010/
June 10-11, 2010
June 28-30, 2010
July 19-21, 2010
July 21-23, 2010
Sept 13-14, 2010
October 6-8, 2010
October 12-15, 2010
October 17-20, 2010
November 8-11, 2010 Editorial Notes, Disclaimers & Disclosures
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