cmonfils | January 15, 2012
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 1/12/2012, www.Thompson.com
Case: Pacific Shores Hosp. v. United Behavioral Health, 2011 WL 6402435 (C.D. Calif., Dec. 19, 2011)
A benefit administrator’s adverse benefit determination was imperfect but sufficient to comply with claims procedure rules, the U.S. District Court for the Central California district concluded in the above case. Discrepancies by reviewing physicians and adjustments made in discharge criteria were not enough to support allegations of claims-procedure violations and overturn the denial, it held. (more…)
Category: California, Claims Procedures, Plan Language |
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cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
A plan participant cannot pick definitions from various state or federal statutes and impose them on the plan where the plan left terms undefined, if the plan applies a common and ordinary meaning to those terms when asked to justify a claims denial.
Applying this rule, a Michigan appeals court affirmed a lower state court’s ruling upholding a plan’s benefits denial for a surrogate mother’s delivery of triplets. (Spectrum Health v. Lehr, No. 298688, (Mich. App., Sept. 8, 2011).) (more…)
Category: Claims Procedures, ERISA, Health Insurance, Michigan |
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cmonfils | November 18, 2011
Employer’s Guide to Self-Insuring Health Benefits October 2011 | Vol. 19, No. 1
A federal district court upheld a plan’s two-pronged denial of: (1) a patient’s pain treatment falling under its insurer’s experimental services exclusion; and (2) the same patient’s emergency admission in response to complications from the treatment.
The denial was reviewed many times by outside physicians who all provided that the pain treatment was not proven, and needed more study to demonstrate efficacy. The assessment matched one of the plan’s exclusions for an experimental treatment. The court rejected arguments that the expert witnesses the plan used were biased, and scientific papers supporting the treatment did not prompt the court to reject the opinions of the expert witnesses. The case is Rasmussen v. Altius Health Plans, 2011 WL 3566867 (D. Utah, Aug. 15, 2011). (more…)
Category: Claims Procedures |
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cmonfils | November 18, 2011
Employer’s Guide to Self-Insuring Health Benefits October 2011 | Vol. 19, No. 1
The sponsor of a self-funded health plan abused its discretion in an ERISA claims dispute after it misquoted plan terms during administrative appeals, asking reviewers questions that didn’t reflect plan exclusions, and leading them to affirm the denial when in fact the claim should have been paid under the plan, a federal court decided. The dispute arose over a procedure to remove a dental cyst that was creating medical problems. The plan contended that the procedure fell under the plan’s exclusion for dental services; while the patient and his doctors said it was a covered medical service involving injuries to the sinus and nose. The plan stood by an expert opinion that if any part of the procedure was dental, then the entire treatment could be denied under the dental exception. The plan’s thirdparty administrator avoided abuse-of-discretion charges because it was not a proper defendant. (more…)
Category: Claims Procedures, Self-Funding |
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cmonfils | November 7, 2011
www.myhealthguide.com
MyHealthGuide Source: Joanne Wojcik, 10/30/2011, Business Insurance Article
Because self-funded health care plans are governed by the federal Employee Retirement Income Security Act, they are exempt from state premium taxes and state laws that mandate minimum coverage requirements making self-funding a less expensive option for employers than traditional commercial health insurance, benefit experts say. (more…)
Category: Claims Procedures, HHS, Self-Funding |
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cmonfils | November 7, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Thompson Blog on HR and Benefits, 11/3/2011, http://smarthr.blogs.thompson.com and Blog Source
Have you asked your doctor or dentist to see his fee schedule? When I did so once, a dentist flatly refused, and as he was showing me the door, he said in effect: “my prices are higher, but that’s what you need to get my quality advantage.” (more…)
Category: Claims Procedures, Transparency |
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cmonfils | July 21, 2011
www.dwt.com By Dipa N. Sudra and Jeff Belfiglio 07.14.11
Health care reform requires nongrandfathered group health plans, both insured and self-insured, to change their internal claims procedures and external review procedures. Even as plans work to implement these rules, the Internal Revenue Service, the Department of Labor, and the Department of Health and Human Services have jointly released amended interim final regulations in response to comments on the interim final regulations issued last July (discussed in a previous advisory). The agencies also issued technical guidance1 and revised model notices.2 (more…)
Category: Claims Procedures, Claims Review, Health Care Legislation |
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cmonfils | May 5, 2011
www.businessinsurnce.com
INNOVATION IS a hallmark of successful leaders in all areas of business, and innovation clearly is a key attribute of the risk managers we honor with our 2011 Risk Manager of the Year award and Risk Management Honor Roll. (more…)
Category: Accountable Care Organizations, Claims Procedures, Claims Review |
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cmonfils | April 25, 2011
www.plansponsor.com
April 19, 2011 (PLANSPONSOR.com) – The effective dates for the new claims and appeals requirements under PPACA have changed more than once (even since we’ve written about this issue before).
Not surprisingly, we have been receiving a number of questions asking us to clarify these various dates.
The Department of Labor issued a grace period – does the grace period apply to all of the new claims and appeals requirements? (more…)
Category: Claims Procedures, Claims Review, PPACA |
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cmonfils | February 2, 2011
www.healthplanlaw.com
January 18, 2011
In the present case, the plaintiff asserts its procedural challenge on the grounds that, given the different versions of the administrative record produced during discovery, many of which lacked important medical records initially provided by the plaintiff, it is impossible to determine what comprises the full administrative record on which the defendants relied when denying the plaintiff’s claim. The Court concludes that this claim justifies discovery beyond the administrative record. The plaintiff’s allegation that the defendants may have failed to consider significant portions of the record may give rise to a procedural challenge of the kind discussed in Killian and may also give rise to an inference of a structural conflict of interest. (more…)
Category: Claims Procedures, Claims Review, ERISA, Litigation |
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Adam V. Russo | November 18, 2010
MyHealthGuide, www.myhealthguide.com
MyHealthGuide Source: Jim Farley, J. P. Farley Corporation, 11/10/2010, www.jpfarley.com
USA Today (10/22/2010) featured a front page article (below) about a small physical therapy firm in Michigan who has successfully sued Blue Cross and Blue Shield of Michigan for tactics that would put the small firm out of business for offering Ford, GM and Chrysler an alternative that would have saved them millions of dollars per year on physical therapy claims. This is the same Blue Cross plan that has had suit filed against it by the U.S. Department of Justice for paying hospitals higher prices in exchange for bigger discounts. (It should be noted, others are being investigated by the feds and states for similar practices.) (more…)
Category: Claims Procedures, Claims Review |
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Adam V. Russo | October 4, 2010
By Jane E. Brody of The New York Times, www.nytimes.com
In times like these, the last thing you need is a hospital bill that can wreck an already fragile budget. This is often the fate of elderly patients who incorrectly assume that Medicare will cover everything.
Not so, as my aunt discovered early last year after a two-night, two-and-a-half-day stay at a for-profit hospital in Florida. There is a lesson for all of us from the following tale: no matter who is footing the bill, hospital charges should be carefully vetted by someone who, with the Internet and perhaps professional help, can decipher the codes and uncover unreasonable and erroneous charges. (more…)
Category: Claims Procedures, Claims Review, Medicare, Never Events, Usual and Customary |
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Adam V. Russo | August 25, 2010
SIIA, www.siia.org
Oklahoma Tax on Paid Claims Ruled Unconstitutional
This afternoon, a recently enacted tax that would have applied to all claims paid in Oklahoma by health plans, was struck down by the Oklahoma Supreme Court.
Earlier this summer, the Oklahoma State Legislature passed a measure, subsequently signed into law by the Governor, which would have assessed a 1% tax on all health claims paid within the State. TPAs of self-insured health plans as well as stop-loss providers were to be taxable entities. (more…)
Category: Claims Procedures, Oklahoma |
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Adam V. Russo | August 5, 2010
Bryan Cave LLP, www.bryancave.com
The Departments of Treasury, Labor and Health & Human Services (the “Departments”) recently issued two more batches of interim final regulations under the Patient Protection and Affordable Care Act, as amended (the “Act”). This new guidance addresses (i) the preventive services coverage mandate, and (ii) the new internal claims and appeals and external review processes. Both sets of interim final regulations are effective for plan years beginning on or after September 23, 2010. Neither requirement applies to grandfathered group health plans. (more…)
Category: Claims Procedures, Claims Review, PPACA, Welfare Benefit Plans |
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Adam V. Russo | July 9, 2010
In the context of an ERISA claim in which the insurer’s structural conflict of interest was a factor in the court’s analysis, the court concluded the record was insufficient to determine if the insured’s drinking antifreeze was accidental in Catledge v. Aetna Life Insurance Co. The policy excluded loss “caused or contributed to by: an intentional self-inflicted injury” or “use of…intoxicants.” According to the death certificate, corroborated by police reports, the insured died after he “drank antifreeze,” which the coroner called an “accident.” The court criticized Aetna for failing to construe what the decedent’s intent was when he drank antifreeze and concluded Aetna should have sought “to clarify the ambiguous record prior to making a decision on the intertwined questions of whether [the insured] died” of accidental causes.
Category: Claims Procedures, Exclusion, South Carolina |
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