bhoffman | August 16, 2010
By Deborah J. Williamson of Warner Norcross & Judd LLP, www.wnj.com
A frequent question of physicians, medical practices and other providers I represent is whether the HIPAA Privacy Rule prohibits them from providing third-party payors with access to medical records for the purposes of an audit. In other words, does HIPAA prevent third-party payors from conducting [...]
bhoffman | 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 [...]
Adam V. Russo | July 9, 2010
In Kehoe v. 1st Source Bank Healthcare Benefits Plan,190 the court affirmed an ERISA plan administrator’s denial of health coverage where claimant had a blood alcohol level of 0.128, as tested at the treating hospital, and the plan excluded “[c]harges resulting from an illness or injury incurred while under the influence of alcohol or illegal [...]
Adam V. Russo | July 9, 2010
Juli Pollitt, a federal employee, had health insurance administered by Health Care Service Corp. (HCSC). In July 2007, HCSC stopped paying claims submitted on behalf of Pollitt’s son Michael and began trying to collect from health care providers any payments made on Michael’s behalf since 2003. According to HCSC, it did this because the Department [...]
Adam V. Russo | July 9, 2010
In light of the Supreme Court’s decision in Glenn, the Second Circuit has reassessed its standard of review governing cases that challenge an ERISA plan administrator’s decision to deny disability benefits in cases where the administrator has a conflict of interest because it has the discretionary authority to determine the validity of the employee’s claim [...]
Adam V. Russo | August 19, 2009
by Paul Raeburn, www.kaiserhealthnews.org
On the evening of March 1, 2008, Gary Diego was relaxing with his wife, Ellen, when she abruptly lost her hearing, began repeating herself, and seemed to be losing her grip.
Adam V. Russo | August 11, 2009
by Jeremy Smerd – Workforce Management, www.workforce.com
A medical billing company may be blowing smoke, but could reimbursing patients for medical marijuana lower drug costs for employers?
Adam V. Russo | August 5, 2009
Reaction from AMA, TMA, GMA, Self-Funded Employer• Getahn Ward, The Tennessean, 5/16/09, Tennessee HRI Article
• Emily Berry, American Medical News, 4/13/09, AMedNews Article
• Tennessee Medical Association (TMA) Legal Department 5/5/09, TMA Alert on HRI Recoupment Letters
Franklin (TN)-based Health Research Insights, has temporarily halted efforts to collect on potential overpayments of medical claims by two Nashville-area [...]
Adam V. Russo | May 28, 2009
by Fred Schneyer of PLANSPONSOR, www.plansponsor.com
After tweaking their standard for how federal judges should handle employee benefits denial cases involving a conflicted plan administrator, federal appellate judges have ordered more hearings in just such a case.
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 [...]
Adam V. Russo | November 6, 2008
Based on the Supreme Court’s decisions in MetLife and LaRue, employers should consider making changes and acting proactively to implement strategies to help ensure that plan disputes are channeled through a committee and that the committee’s decisions receive deference from the courts.
Many corporate officers, employees and board members serve as ERISA fiduciaries. For a fiduciary [...]
Adam V. Russo | November 6, 2008
TPAs rely heavily on ERISA’s requirements that claimants must exhaust their administrative remedies before going to court, and when they do sue, assuming that the Plan documents grant the claim administrator the appropriate discretionary authority, they must show that the claim administrator abused its discretion when denying their claim, before any court will get to [...]
Adam V. Russo | September 23, 2008
by Ron E. Peck, Esq.
Offset: Denying future claims to reimburse the Plan for claims it has paid prior to third party settlement. It is a form of lien reimbursement.
Denial of Future Medical Claims: Denying future claims because they were caused by, and are the responsibility of a third party with whom the insured has settled [...]
Adam V. Russo | June 19, 2008
Shelby County Healthcare Corp, d/b/a Regional Medical Center v. The Majestic Star Casino, LLC group Health Benefit Plan, 2008 WL 782642 (WD Tenn.) has demonstrated that even though the SPD gives the Plan the final decision to accept or deny medical claims, discretion does not apply to the Plan’s TPA.Damon Weatherspoon, a plan participant of [...]
Adam V. Russo | February 20, 2008
The Supreme Court will be granting certiorari to MetLife, et al., v. Wanda Glenn. While MetLife v. Glenn reinforces a third party administrator’s (“TPA”) right to make administrative decisions and interpret the terms of benefit plans when it is not the party funding the plan, this case asks whether a Plan Administrator faces a conflict [...]
