Medical Stop Loss Insurance Is Not a Commodity
Posted By bhoffman on September 2, 2010
By Jim Hoitt of R.E. Moulton, a OneAmerica Company
Welcome To My Site...
The Health Insurance Blog of Attorney Adam V. Russo
Welcome to Passion for Subro! The purpose of this site is to share my passion for the health insurance industry with the rest of you fanatics. I hope this site will be your destination for the latest in health care as well as self insured news across the country. While I envision that this site will serve as a great educational resource, it will also keep you entertained with the funny, difficult, confusing and just plain weird world of self insurance.
Thanks for visiting!
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PHX Announces Acquisition of Crossfire Technologies
Posted By bhoffman on September 1, 2010
PHX, www.phx-online.com
PHX Acquires Crossfire Technologies to Expand PPO Management Services
PHX today announced that it has acquired all of the assets of Crossfire Technologies, Inc., a leading provider of automated medical claim re-pricing software. Crossfire’s Technologies product line includes automated EDI and Web-based claims re-pricing, provider profile data warehousing and fee schedule management. PHX is expanding the number of existing PPO Networks relationships and intends to include access to over 100 regional and national PPO networks across the country. (more…)
Rules Set Process for Claims Appeals
Posted By bhoffman on September 1, 2010
Employers concerned health reform change will add to burdens
By Joanne Wojcik of Business Insurance Magazine, www.businessinsurance.com
WASHINGTON—Interim final rules about the appeals and external claims review processes that nongrandfathered self-insured group health plans must follow under new federal law could prove a challenge for many large, multistate employers, some benefit consultants say.
The challenge is that less than a dozen independent review organizations are qualified to provide those services, the consultants say. (more…)
From the Bench
Posted By bhoffman on September 1, 2010
SIIA, www.siia.org
By Thomas A. Croft, Esq.
I. The Supreme Court Clarifies ERISA Attorney Fee Provision
We have two reasons for reviewing Hardt v. Reliance Standard Life Ins. Co., 130 S. Ct. 2149 (2010). First, it is the latest ERISA decision from the Supreme Court cases define ERISA jurisprudence, they cannot be ignored. Second, the case addresses an issue near and dear to our hearts – attorneys’ fees.
On its facts, Hardt is something of a plain vanilla disability case. Hardt was an executive assistant to the president of Dan River, Inc., a textile manufacturer. After being diagnosed with carpal tunnel syndrome, Hardt applied for long term disability (“LTD”) benefits. Her claim was denied by Reliance Standard Life Insurance Company (“Reliance”), Dan Rivers’ LTD insurer. On appeal, Reliance reversed itself in part and determined that Hardt was totally disabled from performing her current job, thus entitling her to 24 months of coverage. (more…)
Supreme Court Reverses Lower Courts and Restores ERISA Plan’s Discretion
Posted By bhoffman on August 27, 2010
Employer’s Guide to Self-Insuring Health Benefits, Thompson Publishing Group
Employers and other plan administrators are due greater deference in their benefits plan decisions than some lower courts have allowed, the U.S. Supreme Court ruled after admonishing two lower courts for failing to follow the High Court’s prior decisions establishing ERISA law on plan administration.
The High Court also admonished the current administration as well as courts for attempting to introduce more complex, inefficient and costly requirements in plan decision-making, and for encouraging court interference in those plan decisions. (more…)
High Court Reverses Lower Courts, Restores ERISA Plan’s Discretion
Posted By bhoffman on August 27, 2010
Employer’s Guide to Self-Insuring Health Benefits, Thompson Publishing Group
Employers and other plan administrators are due greater deference in their benefits plan decisions than some lower courts have allowed, the U.S. Supreme Court ruled. The Court’s 5-3 opinion in Conkright v. Frommert allows ERISA plan administrators to retain deferential review even after an erroneous interpretation of the plan. The plan was acting in good faith, its miscalculations were honest, the errors were isolated and a “one-strike-you’re-out” approach was unreasonable, Chief Justice John Roberts stated in the majority opinion. Deference should be upheld where possible, because if not, litigation becomes more labyrinthine and frequent, and plan administration becomes more complicated, the Court concluded. However, he noted, patterns of wrong plan interpretations — even in good faith — are still grounds for forfeiting deference.
Employers Expect Larger Rise in Plan Costs
Posted By bhoffman on August 27, 2010
Study shows projected average increase up from 7% this year
By Jerry Geisel of Business Insurance Magazine, www.businessinsurance.com
After years in which annual group health care plan cost increases have held steady in the 6% to 7% range, large employers are expecting much bigger increases in 2011, according to a survey released last week.
Employers responding to a National Business Group on Health survey said they expect costs to shoot up by an average of 8.9% next year, up from a projected average increase of 7% this year. (more…)
White Paper Examines Benefits Plans
Posted By bhoffman on August 27, 2010
Business Insurance Magazine, www.businessinsurance.com
Employers that want to get the most out of their investments in employee benefit programs will want to consider how and where their dollars are being spent and the effect on worker health and productivity, according to a new white paper published by Business Insurance.
“Maximizing Health Care ROI: How to Get the Most Bang for Your Benefits Buck” advises employers how implementing plan designs that appeal to their specific employee populations will encourage them to be smarter health care consumers, seek out preventive care and adopt healthy lifestyles that ultimately will reduce overall health care spending. (more…)
COBRA Subsidy Shelved Amid Growing Budget concerns
Posted By bhoffman on August 27, 2010
By Jerry Geisel of Business Insurance Magazine, www.businessinsurance.com
WASHINGTON—The once politically popular program that provides COBRA premium subsidies for involuntarily terminated employees is winding down as broad congressional support has nearly vanished, experts say.
Embedded in a 2009 economic stimulus measure and renewed several times since then, the program in which the federal government pays 65% of the COBRA premium has enabled millions of employees who lost their jobs and their dependents to keep group coverage by making it more affordable. (more…)
Health Reform: New Subrogation And Reimbursement Rules
Posted By bhoffman on August 25, 2010
Coordination of Benefits Handbook
The government has yet to sort out the conflicting interests involved in subrogation/reimbursement dispute. Because there will be no reform body directly creating subrogation/reimbursement rules, the matter remains one of balancing various laws. For instance, laws in many states limit plans’ ability to recover health expenses based on the “make-whole,” “collateral source” and “common fund” rules. States have an interest in: (1) keeping the cost of auto liability insurance low; (2) ensuring that wrongdoers pay full damages; and (3) making sure attorneys are paid for representing clients. These are at odds with the federal government’s goal of keeping the cost of health coverage reasonable. It remains to be seen if the federal government will try to resolve this through preemption of state laws beyond self-funded ERISA plans.
Health Care Reform: Possible Subrogation And Reimbursement Rules
Posted By bhoffman on August 25, 2010
By Jack B. Helitzer, Esq., Coordination of Benefits Handbook
The federal health care reform law attempted to address two major problems with health coverage in the United States; (1) expansion of coverage to the uninsured; and (2) reducing overall health care costs. Most reform provisions won’t take effect for at least a few years. That’s because time is needed to develop regulations dealing with the vast scope and complexity of those problems, and because of the need to phase in increased costs that reform will cause in its early years. That means we really won’t know whether or not the law will achieve either goal, or even if it will survive the current complex political situation. (more…)
11th Circuit Explains Why It Upheld Plan’s Reimbursement Provision
Posted By bhoffman on August 25, 2010
Coordination of Benefits Handbook
Victims of accidents in subrogation/reimbursement cases have emotional appeal when they argue that tort settlements are reduced without some consideration of the fact that they were not “made whole” or had their recoveries diminished by not requiring a recovering plan to share the legal fees they incurred in making the settlement. There can be cases where the amount of the tort settlement seems to include significant amounts to reimburse losses beyond actual medical expenses incurred by the plan participant and paid by the ERISA plan. In this case, the 11th Circuit upheld an earlier ruling allowing the plan to recover the full amount it paid to a participant who received a much larger settlement. The decision was unusual in the clarity of its explanation of why the subrogation was in fact equitable. The plan gained an advantage by becoming involved in the tort settlement early enough to ensure a separate and identifiable portion of the settlement was set aside. (more…)
Plan Is Entitled to Reimbursement From Tort Settlement Funds, Court Rules
Posted By bhoffman on August 25, 2010
Coordination of Benefits Handbook
Although federal case law is well settled on the principle that an ERISA health plan is entitled to reimbursement of benefits paid from tort settlement proceeds that are clearly identified as such, it appears that attorneys for plan participants still come up with several arguments seeking to avoid such liability. Those arguments often rely on state statutes, but they often raise other issues. A recent decision by a U.S. District Court in Georgia in favor of the plan’s right to reimbursement indicates how modern federal courts dispose of those arguments. The case is Brown & Williamson Tobacco Corp. v. Collier, 2010 WL 1487772 (M.D. Ga., April 13, 2010). (more…)
ERISA Plan Wins Recovery From Settlement; Auto Insurer Must Reimburse Member
Posted By bhoffman on August 25, 2010
Coordination of Benefits Handbook
As we have often seen in cases involving tort settlement proceeds arising from auto accidents, Michigan’s no-fault auto insurance law (Mich. Comp. Laws §500.3135) provides that Michigan drivers can buy secondary no-fault coverage at lower premiums. The law prevents insured health plans issued in Michigan from seeking reimbursement for medical expenses from tort settlement proceeds. (more…)
Self-Insured N.J. Government Entity Can’t Access Tort Judgment Proceeds
Posted By bhoffman on August 25, 2010
Coordination of Benefits Handbook
We are familiar with cases where ERISA and state laws conflict. As we know, self-insured health plans that are subject to ERISA may avoid the application of state laws because of ERISA preemption. As we have seen in our analysis of the case Bash v. State Farm Mutual Automobile Insurance Co. on page 11 of this Newsletter, the objectives of ERISA sometimes conflict with the objectives of state laws. (more…)