Adam V. Russo | 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 post-payment audits? (more…)
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…)
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 drugs as evidenced by a blood alcohol level equal to or in excess of the legal amount allowed in the state where injury occurs or any other drug or alcohol screening test.”191 The court rejected claimant’s contention that de novo review applied because the administrator’s decision “was so unusual that [it] went beyond simply interpreting the Plan and, instead, modified the Plan’s terms and conditions.”192 The court held that the administrator’s interpretation of the exclusion did not modify the plan’s language, which did not require illegal consumption of alcohol to trigger the exclusion but rather than an injury incurred while “under the influence,” an objective standard based on state law.193 The court further held that the administrator’s claim decision was not arbitrary and capricious because it was not unreasonable to incorporate the Indiana motor vehicle intoxication statue, defining 0.08 as the minimum BAC for legal intoxication.
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 of Labor, which tells HCSC which federal employees have what coverage, instructed HCSC that Pollitt’s coverage was for herself only rather than for herself and her family. According to Pollitt’s complaint in this suit, however, HCSC reached this conclusion on its own because the Department of Labor had failed to pay the appropriate premium into a fund that covers the expense of the medical benefits. Instead of checking with the department or with her, Pollitt’s complaint alleged, HCSC abruptly stopped covering Michael’s medical expenses and made demands for reimbursement that subjected her family to humiliation and expense. Just as abruptly, HCSC changed course in October 2007 and started paying the claims again. But even then, Pollitt asserted, HCSC did not inform medical providers, who continued trying to collect from Pollitt the back payments they thought HCDC was dunning them for. (more…)
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 and pays the benefits under the policy. In McCauley, the Second Circuit abandoned its prior standard of review, which allowed courts to review de novo the administrator’s decision when it is shown that a conflict of interest actually influenced that decision, and adopted the Glenn standard that such a conflict of interest is to be “weighed as a factor in determining whether there was an abuse of discretion.” (more…)
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. (more…)
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? (more…)
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 self-insured employers to doctors and other health-care providers.
Under pressure from doctors, Metro Nashville Public Schools and Cookeville (TN)-based trucking company, Averitt Express Inc. asked Health Research Insights to stop sending letters that physicians say assume wrongdoing on their part without a review of related medical records. (more…)
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. (more…)
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 was also the insurer) denied the claim on appeal based on the plan’s preexisting condition exclusion. (more…)
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 accused of breaching its duties under ERISA, the stakes are high. ERISA Section 409 imposes personal liability on a fiduciary that breaches its duty. ERISA authorizes lawsuits against fiduciaries by participants, beneficiaries, the plan administrator, other fiduciaries ,and the U.S. Department of Labor. The federal courts have uniformly held that ERISA’s fiduciary duty is “the highest duty known to the law.” (more…)
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 the merits of their allegations.
Few plaintiffs are able to meet these burdens, and so either don’t sue or often get their lawsuits quickly dismissed. Until recently most courts were not very sympathetic to plaintiffs’ arguments of procedural violations, but things are changing, the most significant development being the Supreme Court’s decision this summer in MetLife v. Glenn. (more…)
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 or will settle, and thus for which the insured has removed liability from the third party and shifted responsibility onto him or herself.
Confusion regarding how a benefit plan and its administrator handle future claims resulting from an incident for which another party is or may become responsible is widespread. The greatest mistakes administrators make is confusing “offset” with “future credits” and other future claims, as well as confusing subrogation with exclusions. (more…)
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 the Majestic Star Casino LLC Group Health Benefit Plan was involved in a single vehicle accident and sustained over $400,000 in medical expenses at the Regional Medical Center. Reports indicated that Weatherspoon had violated Mississippi law by driving under the influence, driving without a valid Mississippi driver’s license and driving without insurance. (more…)
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 of interest if it not only determines whether a claim is payable, but also pays the claim with its own funds. (more…)
