cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
A plan’s decision to circumvent its own written appeals procedures led to ERISA claims. In a dispute involving an experimental service denial, plan administrator Viacom and claims administrator United Healthcare told a plan participant to skip the plan’s normal appeals route and appeal to Viacom, because it might overrule the plan’s exclusion or revise the plan to allow payment for the service. When the plan sponsor fumbled its decision, gave conflicting explanations and took months to ultimately deny the claim, the participant sued alleging unpaid benefits, breach of fiduciary duty and other charges. United managed to get all breach of fiduciary duty charges waived but the Viacom defendants still have to face all charges. Wrongful denial of benefits charges still stand against both defendants. (more…)
Category: Claims Review, ERISA, PPACA, Tennessee |
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cmonfils | September 16, 2011
The Self-Insurer August 2011
By Carolyn Smith, Esq. and John Hickman, Esq., Alston & Bird, LLP
New Claim Review Regulations Ease Compliance Burdens For Group Health Plans
On June 24, 2011, the U.S. Department of Treasury, Labor (DOL) and Health and Human Services (HHS) (collectively, the “Agencies”) jointly issued new interim final regulations (“Final Regulations”) and related guidance regarding the internal appeals and external claim review procedures (“Claims Review Rules”) for fully insured and self-funded group health plans and insurance policies issued in the individual market. These new requirements were added by the Affordable Care Act (ACA). The Claims Review Rules apply only to non-grandfathered group health plans otherwise subject to the health insurance reforms added by ACA. (more…)
Category: Claims Review, DOL, ERISA, External Claim Review, HIPAA, PPACA, Self-Funding |
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cmonfils | August 22, 2011
The Self-Insurer August 2011
By Carolyn Smith, Esq. and John Hickman, Esq., Alston & Bird, LLP
New Claim Review Regulations Ease Compliance Burdens For Group Health Plans
On June 24, 2011, the U.S. Department of Treasury, Labor (DOL) and Health and Human Services (HHS) (collectively, the “Agencies”) jointly issued new interim final regulations (“Final Regulations”) and related guidance regarding the internal appeals and external claim review procedures (“Claims Review Rules”) for fully insured and self-funded group health plans and insurance policies issued in the individual market. These new requirements were added by the Affordable Care Act (ACA). The Claims Review Rules apply only to non-grandfathered group health plans otherwise subject to the health insurance reforms added by ACA. (more…)
Category: Claims Review, DOL, External Claim Review, HHS, HIPAA, PPACA |
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cmonfils | August 4, 2011
Claims Appeal and Review Obligations Lessened to Relief of Plans, Insurers
July, 2011
Thompson Publishing Group
Plans and insurers will have an easier time complying with health reform’s internal appeals and external review rules, under rules the U.S. Departments of Labor, Treasury and Health and Human Services issued June 24.
The changes, such as dropping the requirement for plans to display diagnosis and treatment codes on initial and final notifications of adverse determinations, should ease burdens for employer-sponsored plans. Another change lengthened the time allowed to review urgent care claims from “no more than 24 hours” to “as soon as possible but no more than 72 hours.” (more…)
Category: Claims Review, DOL, External Claim Review, Health Care Legislation, HHS |
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cmonfils | July 28, 2011
www.eric.org Jul 25, 2011
ERIC News Release
For Immediate Release: July 25, 2011
Washington, D.C. — The ERISA Industry Committee (ERIC) today submitted comments on the amendment to the interim final regulations implementing the internal claims and appeals and external review processes under the Patient Protection and Affordable Care Act (ACA). (more…)
Category: Claims Review, PPACA |
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cmonfils | July 28, 2011
www.mintz.com By Alden J. Bianchi and Patricia A. Moran July 19‚ 2011
The “insurance market reform” provisions of the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010 (together, the Act) generally require health insurance issuers in the individual and group markets, and employer-sponsored group health plans, to comply with a series of rules regarding internal claims and appeals and external review processes (collectively, the “claims procedure rules”). The claims procedure rules build on similar requirements enacted more than 30 years ago under the Employee Retirement Income Security Act of 1974 (ERISA), which were designed to ensure that participants in employee benefit plans had access to a full and fair review of disputed claims. They are set out in a new provision of the Public Health Service Act (PHSA) that is carried over into both ERISA and the Internal Revenue Code (the Code). (more…)
Category: Claims Review, DOL, HHS, PPACA |
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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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cmonfils | December 29, 2010
www.hr.cch.com
CCH® BENEFITS — 12/23/10
from Spencer’s Benefits Reports: Twenty-six individuals and organizations responded to a request for comments on operational issues associated with implementation of a federal external claims review process in states that do not have their own external review process.
Public Health Service Act Sec. 2719(b)(1), added by the Patient Protection and Affordable Care Act, and related regulations provide that the Department of Health and Human Services’ Office of Consumer Information and Insurance Oversight (OCIIO) and the Department of Labor’s Employee Benefits Security Administration (EBSA) are authorized to establish an external review process that is similar to a state external review process for group health plans and health insurance coverage if a state has not established such a process. (more…)
Category: Claims Review |
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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 29, 2010
By Stephen D. Rosenberg of Boston ERISA & Insurance Litigation Blog, www.bostonerisalaw.com
Well, here’s a story on an unpublished Ninth Circuit decision on the impact on the duty to defend of related claims provisions in claims made insurance policies. Although policies vary in the language and structure they use to accomplish it, these provisions essentially declare a claim made during a policy period to be linked to earlier events or an earlier claim if they all arise from related events, with there being no coverage if the earlier related events occurred before the policy period of the policy under which coverage is being sought. The operation of these provisions is of crucial importance for the operation of claims made insurance policies and for insurance programs built on them, in that a claims made policy is built around the idea that the policy will only provide coverage for claims – such as lawsuits – actually first made against the insured during the effective period of that policy, and that the policy won’t provide any coverage if the loss for which coverage is sought relates to a claim that began before the commencement of that policy period. Claims made policies are priced on only covering claims actually first arising during the policy period – and not on covering those that started before the policy period or were not made until after it ended. By precluding coverage when a particular claim actually stems from events or another claim that predated the policy, the related acts language is the mechanism for effectuating this intent. I will warn you up-front that this is a very simplistic introduction to a fairly complicated subject, but it captures the idea. (more…)
Category: 9th, 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 | September 8, 2010
By Joanne Wojcik of Business Insurance Magazine, www.businessinsurance.com
DALLAS—A pilot project that launched this week will help nine employer members of the Dallas-Fort Worth Business Group on Health more effectively tailor their benefits to better address worker health and productivity while also lowering overall health care costs. (more…)
Category: Claims Review, Welfare Benefit Plans |
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