Adam V. Russo | December 29, 2008
In Avmed, Inc. V. BrownGreer, PLC, 2008 WL 4909535 (5th Cir. 2008), the 5th Circuit Court of Appeals hurt the health insurance subrogation industry when it comes to Vioxx claims. The court recognized that ERISA health plans have legitimate rights of subrogation and reimbursement for medical expenses paid to participants who suffered health issues after taking Vioxx, a drug intended to relieve pain.
The Court questioned whether settlement funds belonged to the subrogated plans and indicated that technical problems in mass tort multi-district litigation makes it difficult for plans to perfect their subrogation rights. (more…)
Category: 5th, Subrogation |
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Adam V. Russo | December 22, 2008
by Anna Wilde Mathews of The Wall Street Journal
You might expect to pay more if you choose a doctor outside your insurer’s network. But what if you don’t know a doctor’s status — or are in no position to ask? The result can be a nasty surprise known as balance billing.
Insured patients are sometimes hit with unforeseen charges after emergencies, when they are taken to the closest hospital regardless of whether the facility accepts their insurance. Consumers also may be billed after visiting in-network hospitals if they received treatment from medical providers who work there but don’t participate in the same health plans. When that happens, insurers often pay part of the doctors’ fees, and the physicians bill patients for the difference. This is the practice known as balance billing, and it can leave consumers battling both the insurer and the medical provider to get the charge reduced. (more…)
Category: News |
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Adam V. Russo | December 11, 2008
In April 2006, Massachusetts became the first state to require that all of its residents purchase health insurance. The plan had support from organizations and individuals across the political spectrum. The Massachusetts plan was a response to today’s health care costs, which are rising twice as fast as inflation, making insurance increasingly unaffordable for many employers and individuals. (more…)
Category: Massachusetts |
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Adam V. Russo | December 5, 2008
The leading health insurance trade group recently offered its own coverage proposal that calls for Congress to slow the growth of care costs by 30% in five years with a total savings of more than $500 billion.
America’s Health Insurance Plans (“AHIP”) stated that the money could be used to fund coverage of the uninsured and to cut costs for those with insurance. AHIP called on Congress to establish an advisory group to recommend action to reduce wasteful spending, change how providers are paid, and reducing administrative costs. (more…)
Category: News |
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Adam V. Russo | December 4, 2008
I recently received an email from a colleague of mine, James R. McKown, CEO of Recovery Data Connect, L.L.C., notifying me about a 9th circuit decision emphasizing three major factors in the case: plan language creating an automatic lien, rejecting the Made Whole Doctrine and preventing the plaintiff from challenging related medical claims due to a Sworn Declaration. To read the entire 9th circuit decision, Laborers v. Hill, United States District Court for the Northern District of California (November 25, 2008). Click Here
Category: 9th |
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Adam V. Russo | December 3, 2008
By Joanne Wojcik of Business Insurance, www.businessinsurance.com
The National Priorities Partnership is calling on all employers, health insurers, medical professionals, labor and government organizations and other interested parties to commit to a core list of six objectives its members believe will improve the quality of health care and lower costs within the next three to five years.
The six goals focus on improvements in patient and family engagement, population health, patient safety, care coordination, palliative and end-of-life care and overuse or misuse of health care resources. (more…)
Category: News |
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Adam V. Russo | December 3, 2008
By Joanne Wojcik of Business Insurance, www.businessinsurance.com
The growing popularity of consumer-driven health plans is influencing the size of deductibles in traditional preferred provider organization plans, a study concludes.
Meanwhile, the rate of increase in group health care plan costs showed little change from the past few years, according to the National Survey of Employer-Sponsored Health Plans, conducted annually by New York-based consultant Mercer L.L.C. (more…)
Category: News |
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Adam V. Russo | December 3, 2008
In Gagliano v. Reliance Standard Life Ins. Co., 2008 WL 4916330 (4th Cir. 2008), an employee’s claim for long-term disability benefits was denied on the ground that she was not disabled under the terms of the plan. The court ordered an independent medical examination that stated the employee was disabled but the plan administrator (who was also the insurer) denied the claim on appeal based on the plan’s preexisting condition exclusion. (more…)
Category: 4th, 6th, Claims Review, ERISA |
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Adam V. Russo | November 21, 2008
Farie v. Jeld-Wen, Inc., 2008 U.S. Dist. LEXIS 88893 (N.D. Ohio) (Oct. 31, 2008).
The plan participant was injured in a car accident and refused to reimburse the health plan for medical claims paid.
The Court stated that “the make-whole rule provides that an insurer cannot enforce its subrogation rights unless and until the insured has been made whole by any recovery, including any payments from the insurer”. (more…)
Category: 6th, Made Whole Rule |
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Adam V. Russo | November 18, 2008
The Latest Article from The Health Care Blog by Brian Klepper
These are, as the Chinese curse reputedly called them, interesting times.
If the burst of new Democratic health care reform proposals is any indication, a fresh breeze of the Obama campaign’s “Yes We Can” optimism is blowing across the nation. Mr. Obama’s team is expected to make health care one of its priorities. First out, though, was Senate Finance Committee Chair Baucus (D-MT), who introduced an aggressive health care reform package that builds on Mr. Obama’s campaign platform of cost controls and extended coverage. Senator Kennedy (D-MA) and Representatives Dingell (D-MI) and Stark (D-CA) are expected to offer proposals soon, and undoubtedly there will be others. (more…)
Category: News |
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Adam V. Russo | November 11, 2008
By Jerry Geisel, Business Insurance, November 10, 2008
Washington-The election of Barack Obama as president will change the health care legislative landscape dramatically when the Illinois Democrat takes office January.
For the first time since Bill Clinton assumed the presidency in 1993, the occupant of the Oval Office with have as a goal developing federal legislation to drastically reduce the number of people who lack health insurance. (more…)
Category: News |
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Adam V. Russo | November 11, 2008
Most lawsuits to recover damages in car accidents are resolved in state courts. State courts will order that at least a portion of the judgment be deposited into court when it appears that a health plan may have the right to reimbursement. But can a state court override the right of the health plan to recovery? This issue was addressed in Iowa Health System, Inc. v. Graham, 2008 WL 2959796 (C.D. Ill., July 30, 2008). (more…)
Category: 5th, 7th, Subrogation |
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Adam V. Russo | November 11, 2008
The U.S. District Court in North Dakota recently sorted out conflicting COB provisions of motor vehicle and health coverage. The court ruled that the motor vehicle policy had to pay its maximum benefits before the health plan began paying its benefits. In the North Dakota case, an auto policy restricted benefits to $5,000 in the event the policyholder is covered by another policy; the health plan mandated that the auto insurer must pay up to its policy limit before the plan would begin paying. The court upheld the health plan’s decision. (more…)
Category: 8th, North Dakota |
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Adam V. Russo | November 11, 2008
Motor vehicle insurance policies usually include personal injury protection (PIP) coverage that will reimburse the insured and/or a family member for a limited amount of medical expenses regardless of who was at fault. Many current motor vehicle policies limit the PIP coverage to relatively small amounts if the injured person has other health coverage. The general idea of that approach is to provide greater PIP coverage, but to permit the auto insurer to have secondary liability if the injured person has other coverage. (more…)
Category: Coordination of Benefits, Massachusetts |
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Adam V. Russo | November 10, 2008
Here is a sneak preview of Attorney Russo’s article that will be published in the Winter 2009 edition of The Subrogator
By Adam V. Russo[i]
As a subrogation attorney, sometimes I receive a case where the settlement funds are nowhere to be found. Regardless of this fact, the plan is asking me to obtain a 100% recovery three months after the settlement. While I know there is case law out there stating that plans have the right to recover even if the funds aren’t identified, the question is one of practicality. In the real world, how will you actually recover the money if you don’t know where the settlement proceeds are? Let’s say that you have a judgment in the underlying case but the patient has already spent the money; what good is the judgment when the chances of ever seeing a penny are slim? If the money is spent, regardless of your rights, what is the possibility that you will ever actually see it?
(more…)
Category: News, Subrogation |
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