Adam V. Russo | March 31, 2009
Article from CCH®, www.health.cch.comAn organization that operates dialysis centers in small towns and rural areas could not demonstrate that a large health insurance provider’s decision to reduce reimbursement rates on dialysis treatment received at out-of-network facilities amounts to taking into account or differentiating the level of coverage provided to patients with end-stage rental disease (ESRD) and those without ESRD. The insurance provider cut its reimbursement rate for out-of-network dialysis by 88 percent in January 2007, to levels below the customary charges associated with such care. The dialysis provider argued that this amounted to a manipulation of reimbursement rates designed to target out-of-network providers and a violation of the antidiscrimination provisions of the Medicare as Secondary Payer Act. The insurer’s decision, however, does not violate the statute’s implementing regulations because the same level of reimbursement is provided for out-of-network dialysis, regardless of whether the patient suffers from ESRD. Moreover, the insurer’s decision does not alter the benefits granted to a Medicare beneficiary as opposed to a patient who is not enrolled in Medicare. The dialysis provider’s Medicare as Secondary Payer Act claim is dismissed. The claims alleging breach of contract under state law and violations of the Employment Retirement Insurance Security Act (ERISA) are not dismissed and may proceed.
Category: ERISA |
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Adam V. Russo | March 31, 2009
by Amy Lynn Sorrel, AMNews staff, www.amednews.comSan Francisco’s universal health access program scored another victory in the courts in a decision that has set the stage for a possible U.S. Supreme Court showdown over the use of employer mandates as part of health system reform.
The full 9th U.S. Circuit Court of Appeals in March upheld an earlier decision by a panel of three of its judges validating the city program’s employer spending provision. The provision requires businesses to contribute a minimum amount toward workers’ health coverage or pitch in to a city fund for Healthy San Francisco, a universal access program offering primary and preventive care to uninsured residents. (more…)
Category: 9th |
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Adam V. Russo | March 31, 2009
As Co-Chair for the NASP Litigation Skills Conference, Adam V. Russo, Esq. will be speaking at the Session 2 Health Track on Friday April 3rd at 8:30am.
Click here to see the entire presentation.
Attorney Russo will also be speaking at the General Track on Friday April 3rd at 2:45pm along with, Gary Wickert, Daran Kiefer, Regis Moeller & Brooke Flaherty.
Click here to see the entire presentation.
Category: ERISA |
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Adam V. Russo | March 24, 2009
Since the Glenn decision, a number of circuits have had an opportunity to consider and apply the Glenn Court’s reassessment of ERISA’s standard of review.Roumeliote v. LTD Plan for Employees of Worthington Industries, 298 Fed. Appx. 472 (6th Cir. 9/11/2008).
This was the first circuit to apply Glenn since Glenn was a Sixth Circuit decision and the Sixth Circuit’s determination in that case was affirmed by the Supreme Court. The Sixth Circuit affirmed the district court’s decision that the claim administrator’s denial of benefits was not arbitrary. (more…)
Category: 11th, 4th, 6th, 9th |
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Adam V. Russo | March 24, 2009
The American Recovery and Reinvestment Act (the “Act”; also informally known as the “Stimulus Bill”) was signed into law by President Obama on February 17, 2009. The Act contains modifications to HIPAA’s Privacy and Security Rules. These changes will likely require every business associate agreement to be modified. (more…)
Category: News |
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Adam V. Russo | March 23, 2009
by Dave Lenckus of Business Insurance
While third-party administrators can deliver efficiencies for self-insured programs, risk managers should require protections and maintain vigilant oversight for instances when the claims process breaks down, risks managers say.
If “properly vetted,” a TPA can provide great service and “enhance metrics and decision making” said Wayne L. Salen, director of risk management for Labor Finders International Inc, In Palm Beach Gardens, Fla. (more…)
Category: Third Party Administrators, Welfare Benefit Plans |
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Adam V. Russo | March 23, 2009
by Jerry Geisel of Business Insurance
San Francisco- The 9th U.S. Circuit Court of Appeals’ decision last week not to review a 2008 appeals panel ruling upholding a San Francisco health care spending law brings one step closer to a potential U.S. Supreme Court review and perhaps a final resolution on the legality of employer spending mandates.
In a case followed by employers nationwide due to its potential impact on the design, cost and administration of corporate health plans, a majority of appeals court members rejected a request for the full appeals court to review a unanimous ruling by a three-judge panel of the court that the law could stand. (more…)
Category: 9th |
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Adam V. Russo | March 23, 2009
In the case of Humana Health Plans, Inc. v. Patti Powell, 07CV385 (W.D. Ky. Feb. 25, 2008), the Western District of Kentucky issued an important decision regarding ERISA preemption of Kentucky Stat. § 441.188. This Kentucky Statute at issue in the case limits a subrogated party’s rights where that party fails to intervene in the state court action. Previously, the Court had decided that this section was not preempted by ERISA, but in this decision the Court reconsidered and reversed itself. (more…)
Category: 3rd, 6th, Kentucky |
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Adam V. Russo | March 20, 2009
by Martin Trussell of the World Health Care Blog
This past week I was in Washington DC to attend the 28th ECFC Annual Meeting. The conference attracted employers, third party administrators, and others who are involved in providing or administering flexible benefits programs which include: flexible spending accounts, Section 125 plans, health reimbursement arrangements, dependent care accounts, health savings accounts and more. On Thursday we made a trip to Capitol Hill where we had the chance to meet with staffers representing one Democratic and two Republican lawmakers. We also heard from Sen. Ted Kennedy’s chief healthcare policy advisor, former CMS director, Tom Scully, and former Sen. Bob Dole, among others. They all agreed on one thing: the current healthcare system is not working and needs to be fixed. They also agreed that this is the best chance Washington has had in years to reform the healthcare system. And, they all expressed the desire to preserve the existing employer-based system, and for the legislative process to be inclusive and bi-partisan. Furthermore, there was agreement about the problems that are afflicting the system, namely, access, affordability and quality were themes that echoed throughout the day. I also sensed a universal desire to get it right, and to make healthcare an economically sustainable proposition for the government, employers, and individuals. The steaks are huge. (more…)
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Adam V. Russo | March 20, 2009
from The Advocate Staff of The Connecticut Post
Updated: 03/07/2009 08:09:09 AM EST
It’s rare for the U.S. Supreme Court to opine on retirement plan beneficiary designations, so when it does, it’s newsworthy. A few weeks ago, the court decided a case, Kennedy v. DuPont Savings and Investment Plan, that involved whether a form as benign as a beneficiary designation overpowers a divorce decree. (more…)
Category: 2nd, ERISA |
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Adam V. Russo | March 20, 2009
from CCH® PENSION AND BENEFITS http://hr.cch.com/news/pension/
from Spencer’s Benefits Reports: An employer committed an “egregious” failure to comply with the notice requirements of ERISA Sec. 204(h) when it converted its traditional defined benefit plan into a pension equity plan. This was the ruling of the Fourth Circuit U.S. Court of Appeals in Brady v. The Dow Chemical Company Retirement Board (No. 07-2040). (more…)
Category: ERISA, News |
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Adam V. Russo | March 20, 2009
By Jay Newton-Small of Time Magazine
Friday, Mar. 13, 2009
A bipartisan group of nine U.S. Senators, after meeting for nine months behind closed doors, is nearing an agreement on the broad strokes of a health-care-reform bill. The so-called Gang of Nine – though its number expands and contracts depending on the meeting – is hammering out the finer points as they prepare to enter the drafting phase of the negotiations, sources from three Senate offices involved in the talks told TIME. (more…)
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Adam V. Russo | March 19, 2009
From the Clear Direction Blog www.cleardirectionblog.com
Posted: 18 Mar 2009
A recurring issue for health plan subrogators is what language is sufficient to override the make whole rule. On the one hand, Circuits like the Fifth Circuit have held that no particular language is required to overcome the make whole rule. In the Fifth Circuit (and others like it), plan language simply providing for 100% recovery is sufficient. (more…)
Category: 9th, Made Whole Rule, Summary Plan Description |
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Adam V. Russo | March 4, 2009
For years, The Phia Group has argued that requisite signed subrogation agreements are a mistake. Often, plan documents include language which states that if a third party may potentially be responsible for charges, the Plan will not process these charges without a signed subrogation agreement from the plan member. (more…)
Category: Never Events |
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Adam V. Russo | March 4, 2009
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the Parity Act) was passed on October 3, 2008, and was signed into law by President Bush the same day it passed Congress. The compliance date for each health plan is the annual renewal that occurs 12 months after the date the Parity Act became law (October 3, 2008). The Parity Act states that the law must be complied with even if the regulations have not been published by the effective date of compliance. Therefore, employers need to begin to evaluate their plan designs and establish a strategy for compliance. (more…)
Category: Never Events |
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