Adam V. Russo | April 29, 2010
This case is extremely important as it stands for premise that the Plan expects premium payments and subro rights in exchange for paying benefits. Specifically, it states that subrogation defrays health insurance costs. The Defense made an argument stating that Zurich’s claim for reimbursement violates ERISA’s anti-discrimination provision but Court disagreed stating that plan language applied to all participants. This is a great case to read and cite as it brings us bases from many Circuits – even Shank. Enjoy!!
View the article here. Zurich Vs. O’Hara
Category: 11th, ERISA, Federal Circuits, Subrogation |
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Adam V. Russo | April 29, 2010
While the U.S. healthcare overhaul law passed last month included help for states to cover some costs of making sure all Americans have health insurance, in the long term some states may find their budgets stretched, Moody’s Investors Services said on Tuesday.
Healthcare Reform
The burdens could be even greater if the recovery from the recession that began in 2007 is slow or mild, which could leave states strapped to pay for their current responsibilities, let alone the expanded healthcare demands, Moody’s said. (more…)
Category: Health Care Legislation, Medicaid |
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Adam V. Russo | April 29, 2010
Medical spending rule could mean less focus on cost-containment
Joanne Wojcik
If insurers are forced to exclude medical cost-containment activities from medical loss ratio calculations, they may place less emphasis on lowering health care costs, industry analysts warn.
The Patient Protection and Affordable Care Act establishes new minimum loss ratios for health insurers. Beginning on Jan. 1, 2011, insurers will be required to spend at least 80 cents of every premium dollar paid by individuals and small groups, and no less than 85 cents of premiums collected from large groups, on direct medical care expenses. Insurers that do not meet these thresholds will be required to rebate the difference to policyholders or deduct it from the subsequent year’s premiums. (more…)
Category: Health Care Legislation |
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Adam V. Russo | April 29, 2010
Health network examined for possible antitrust violations
By Robert Weisman and Liz Kowalczyk
The US Department of Justice has opened a civil investigation into possible anticompetitive behavior by Partners HealthCare System Inc., the region’s most powerful hospital and physician network.
In a letter sent to Partners and the state’s three largest health insurers on April 19, investigators from the Justice Department’s antitrust division demanded documents relating to Partners’ “contracting and other practices in health care markets in Eastern Massachusetts.’’ (more…)
Category: Massachusetts, News |
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Adam V. Russo | April 28, 2010
Still plenty of work to do on healthcare reform: Even with preservation of the employer-based healthcare system, there remains a big challenge to influence the new reality of healthcare to accommodate self-insurance. SIIA government relations specialists will interpret the new law to members in special one-day seminars (May 18 in Atlanta, June 15 in Phoenix and June 30 in Chicago; details on www.siia.org). But now that Congress has delivered the new law, it’s the job of federal agencies to put it to work, and that provides opportunities to make the law work as well as possible for self-insurance. SIIA lobbyists have a long list of targeted policies to work on with the agencies. (more…)
Category: Health Care Legislation |
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Adam V. Russo | April 27, 2010
In Hall v. Newmarket Corp, Aetna Life Insurance Co., et al. ___F.2d___(D.C. MS. 2009), Theresa Hall was covered through her employer, Newmarket, under a self funded arrangement that was administered by Aetna. When her plant closed down she continued coverage through Aetna and paid premiums to Aetna from 2001 to 2004, when she switched over to Blue Cross Clue Shield. (more…)
Category: ERISA, Mississippi, Preemption |
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Adam V. Russo | April 27, 2010
In Hartsfield, Titus & Donnelly LLC v. Loomis Co., (DC NJ 2010), the employer (“Hartsfield”) sued an insurance agency (“Loomis”) that had administered its employee medical benefits plan because the TPA had made payments in excess of the minimum allowed under the Plan in three instances –two infertility claims and one substance abuse claim in excess of the Plan’s $35,000 lifetime limit. (more…)
Category: ERISA, Third Party Administrators |
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Adam V. Russo | April 26, 2010
Nytimes.com
Four years after Massachusetts enacted its ambitious health care reform, the state has achieved its goal: covering most of the uninsured without seriously straining its budget. Most citizens seem to like it.
Massachusetts cannot stop there. It also needs to figure out how to rein in the escalating costs of medical care and health insurance. The new national reform law includes many provisions designed, over time, to reduce costs, but Massachusetts will have to move sooner. (more…)
Category: Health Care Legislation, Massachusetts |
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Adam V. Russo | April 26, 2010
Businessinsuarance.com
Jerry Geisel
WASHINGTON—A provision in the new health care reform law requiring employers to give low-paid employees vouchers to purchase coverage in state health insurance exchanges could sock employers with even bigger health insurance cost increases. (more…)
Category: Health Care Legislation |
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Adam V. Russo | April 26, 2010
(CN) – The Supreme Court on Tuesday reversed a 2nd Circuit ruling in the tangled world of ERISA law, saying the circuit incorrectly allowed a lower court to refuse to defer to a plan administrator’s interpretation of a plan for re-hired workers after an administrator’s previous, unrelated interpretation was found to be invalid. (more…)
Category: ERISA, Supreme Court |
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Adam V. Russo | April 26, 2010
By Arthur D. Postal
WASHINGTON BUREAU — The U.S. Supreme Court has issued a ruling that appears to limit the ability of the federal courts to review benefit plan administrators’ decisions from scratch.
Members of the court today handed down a 5-3 decision holding that a federal district court has an obligation to defer to a “reasonable interpretation” made by an administrator of a plan governed by the Employee Retirement Income Security Act in cases in which the plan administrator has arrived at a decision outside of an administrative claim for benefits. (more…)
Category: ERISA, Supreme Court |
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Adam V. Russo | April 23, 2010
I am on my way back from La Jolla, CA where I presented “New Methods for Maximizing the Identification & Successful Outcome Associated With Subrogation Events” at Axia’s 2010 Client Symposium held at The Lodge at Torrey Pines.
Click here to see my entire PowerPoint presentation.
Category: Subrogation |
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Adam V. Russo | April 20, 2010
Plaintiffs argue that Medical Mutual, in its processing of insurance claims, violated the federal RICO statute. Specifically, Plaintiffs allege that Medical Mutual “acted to delay, diminish and deny payment of . . . lawful claims of patient-insureds as submitted by out-of-network health providers . . . through a scheme or artifice, utilizing the U.S. Mail and demonstrating a specific intent to defraud the patient-insureds and out-of-network health-care providers.” (Compl. P 51.). . . . (more…)
Category: Health Care Legislation, Preemption |
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Adam V. Russo | April 20, 2010
April 7, 2010 (PLANSPONSOR.com)
A coalition of mental health care benefits organizations has filed a suit seeking to prevent the implementation of an interim final rule requiring parity for mental health benefits.
Business Insurance reports that the suit filed last week in U.S. District Court in Washington by the Coalition for Parity Inc. alleges that regulators failed to provide a “true and complete comment period,” which has resulted in “confusing, flawed and untested requirements.” In addition, while the interim final rule would ban the use of separate deductibles for mental health and medical treatment, the coalition says a single deductible for mental health and other medical services is a “requirement found nowhere” in the 2008 law. (more…)
Category: Health Care Legislation, Mental Health Parity |
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Adam V. Russo | April 20, 2010
Introduction
Over the course of the past several years, the value proposition of Preferred Provider Organizations (PPOs) has come under increasing scrutiny. Many have thought that if price can be controlled, health care costs can be controlled or at least mitigated. The truth is that health care costs are an intricate and complex balancing act between price and utilization (here simply defined as the number of units consumed). Attempts to control one have always resulted in equal and opposite reactions in the other. PPOs perform a necessary service for the industry, but their clout seems to be fading and with it, their value proposition has been called into question. (more…)
Category: Fiduciary Liability, Provider Reimbursement, Third Party Agreements |
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