cmonfils | May 3, 2011
Coordination of Benefits April 2011 | Vol. 19, No. 2
Once again we have a case involving a dispute — between Medicare and a survivor of a deceased Medicare beneficiary — over who has the first right to recovery from a third party’s obligations to the Medicare beneficiary. The case deals with Medicare’s rights under the Medicare Secondary Payer (MSP) law (42 U.S.C. §1395y(b)(2)). The MSP law provides that Medicare can recover benefits it paid from amounts that the Medicare beneficiary recovers from a third party. (more…)
Category: 11th, Medicare, Nevada |
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cmonfils | May 3, 2011
Coordination of Benefits April 2011 | Vol. 19, No. 2
It is well established that a health plan subject to ERISA can recover the benefits it paid from identifiable tort settlement proceeds held by the plan participant’s attorney. When those proceeds are identifiable as to their source an equitable lien can be asserted against the proceeds. If a self-funded ERISA health plan is subject to the common fund rule, both the attorney and the plan would have to share client’s attorney’s fees, and each of them would bear a pro rata share of the tort settlement proceeds (that is, the common fund). (more…)
Category: 9th, California, Common Fund |
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cmonfils | April 25, 2011
www.erisalawyerblog.com
By Stanley D. Baum on April 21, 2011
In Hansen v. Harper Excavating, Inc., No. 08-4089 (10th Cir. 2011), the plaintiff, Jeffery Hansen (“Hansen”), had worked for the defendant, Harper Excavating, Inc. (“Harper”), for six months beginning in 2003. During this time, he attempted to enroll in Harper’s health insurance plan (the “Plan”). The Plan is subject to ERISA. However, unknown to Hansen, Harper never enrolled him in the Plan, although it did deduct Plan contributions from his paycheck. (more…)
Category: 10th, ERISA |
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cmonfils | April 25, 2011
www.mwe.com
April 15, 2011
The ruling in Seff V. Broward County has helped to establish guidance as to what is permissible with respect to the design of wellness programs under the Americans With Disabilities Act (ADA). The U.S. District Court for the Southern District of Florida ruled that Broward County’s wellness program fell within the ADA’s safe harbor provision. (more…)
Category: 11th, Florida, Wellness |
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cmonfils | April 11, 2011
www.myhealthguide.com
MyHealthGuide Source: John Eggertsen, Esq., Eggertsen Consulting, P.C., www.jhelaw.com
The U.S. Court of Appeals for the Sixth Circuit April 6 reversed an injunction that required Blue Cross Blue Shield of Michigan (BCBSM) to provide a multiemployer health fund with documents detailing BCBSM’s discount arrangements with medical providers (Pipefitters Local 636 Insurance Fund v. Blue Cross & Blue Shield of Michigan, 6th Cir., No. 09-2294, unpublished 4/6/11). (more…)
Category: 6th |
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cmonfils | March 25, 2011
www.sfgate.com
Thursday, March 17, 2011
ERISAclaim.com announced 2011 free webinars to examine a recent federal appeals court decision, USA v. Eriksen, (9th Cir. Case:10-30056, ID:7673525, 03/09/2011), affirming the ERISA Embezzlement Convictions against two defendants administering a 401(k) plan, as a part of its new Plan Assets Recovery & Audit Programs to assist self-insured health plans in fiduciary compliance and plan assets recovery. The new Webinars will examine the Court Decision’s impact, along with recent DOL Contributory Plans Criminal Project, on ERISA Health Plan Overpayment Recoupment Market, in case of any TPA’s failure to remit recovered plan assets from healthcare providers to the self-insured ERISA plans and failure to report recouped plan assets to DOL and IRS on 5500 Forms, in a healthcare industry with an estimated recouped plans assets in billions of dollars. (more…)
Category: 9th, ERISA, Provider Reimbursement |
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cmonfils | March 18, 2011
www.healthplanlaw.com Roy Harmon III
March 15, 2011
It is well-established that ERISA plan participants and beneficiaries may assign their rights to their health care provider. Misic v. Bldg. Serv. Employees Health & Welfare Trust, 789 F.2d 1374, 1378-79 (9th Cir. 1986). As an assignee, the provider has standing “to assert the claims of his assignors.” Id. at 1379. A Plan may also prohibit the assignment of rights and benefits. Davidowitz v. Delta Dental Plan of California, Inc., 946 F.2d 1476 (9th Cir. 1991). Both the Braun and Rudolph Plans prohibit the assignment of benefits. (more…)
Category: 9th, Attorneys' Fees |
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cmonfils | March 18, 2011
www.chiroeco.com
March 14, 2011 — The International Chiropractors Association (ICA) announced today that its claims challenging the overpayment recovery practices of various Blue Cross Blue Shield entities were upheld by Judge Matthew F. Kennelly of the United Stated District Court in Chicago, IL, in Pennsylvania Chiropractic Association, et al. v. Blue Cross Blue Shield Association, et al., Case No. 1:09-cv-05619. (more…)
Category: 7th, Illinois, Provider Reimbursement |
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cmonfils | March 10, 2011
www.healthplanlaw.com March 4, 2011 •
“ . . . [I]n order for Principal to reasonably deny S.W.’s hospital charges, substantial evidence had to support its determination that the primary focus of her hospitalization was mental health treatment, i.e., treatment designed to alter her behavior. While there is certainly evidence that mental health treatment was one focus of S.W.’s hospitalization, we conclude there is insufficient evidence to support the determination that S.W.’s mental health was the primary focus of the hospitalization.“ (more…)
Category: 8th, Mental Health Parity |
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cmonfils | March 1, 2011
www.healthplanlaw.com
February 21, 2011 • Roy Harmon III
In Comrie v. IPSCO (7th. Cir. 2/18/11) the Seventh Circuit considered whether a discretion-conferring clause in a SERP plan document should be applied when the plan administrator is not a fiduciary. Noting a difference of opinion on the issue, the Seventh Circuit, via Judge Easterbrook, saw the issue as very simple to resolve: (more…)
Category: 7th, 8th, ERISA |
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cmonfils | March 1, 2011
www.wsj.com
FEBRUARY 28, 2011. By AVERY JOHNSON
Maggie Haslam’s five-year-old autistic son, Drew, has undergone intense behavioral, physical and speech therapy that helped him learn to dress himself and communicate such concepts as “over” and “under.”
The next big issue for the federal health law as it moves toward implementation is how regulators will define so-called essential benefits—the basic medical services that health plans must cover under the law. (more…)
Category: 2nd, Health Care Legislation |
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cmonfils | February 7, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Coordination of Benefits Handbook, Thompson Publishing Group, 2/3/2011, www.thompson.com
Case: Lafferty v. Providence Health Plans, 2011 WL 127489 (D. Ore., Jan. 14, 2011) related to the fees; the underlying case was decided in April 2010.
Editor’s Note: The health plan in this case is not self-funded. However, ERISA is cited by the Court. Many self-funded plans deny coverage and payment for experimental treatment. This case shows the outcome of a specific case when payor denial decisions go beyond what is deemed acceptable.
Preface from Mr. Leeuwenburgh: This case may be instructive to see the boundaries for an experimental treatment denial. If the policy was explicitly stated — we’ll deny your whole episode of care if we unbundle it and find you used any part that was experimental — and if this plan had followed ERISA’s review and appeal procedures do you think the insurer could have justified its denial? (more…)
Category: ERISA, Federal Circuits |
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cmonfils | February 2, 2011
www.healthplanlaw.com
January 26, 2011 •
The second prong of the Pascack test is also satisfied. Plaintiff identifies no other “independent legal duty” that would support its claims. Plaintiff’s argument that this is a “rate of payment” case is of no avail. 6 Plaintiff admits that it has no contractual relationship with any Defendants. At the same time, it argues that its right to payment is dependent upon assignments of benefits. The amount of payment (i.e., the “rate”) at issue would necessarily implicate the rates in the ERISA plans under which Plaintiff claims it has received assignments. (more…)
Category: ERISA, Federal Circuits, Litigation, Preemption |
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cmonfils | January 25, 2011
http://www.leagle.com/xmlResult.aspx?xmldoc=In%20FCO%2020110118108.xml&docbase=CSLWAR3-2007-CURR
JOHNSON CONTROLS, INC. v. FLAHERTY
JOHNSON CONTROLS, INC., in its capacity as fiduciary for the Johnson Controls, Inc. Welfare Plan, Plaintiff-Appellee,v.DANIEL J. FLAHERTY, METNICK, LEVY & LONG, P.A., Defendants-Appellants. (more…)
Category: 11th |
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cmonfils | January 12, 2011
www.healthplanlaw.com
January 7, 2011 • Roy Harmon III
ERISA provides federal courts with jurisdiction to review benefits determinations made by fiduciaries or plan administrators. 29 U.S.C. § 1132(a)(1)(B); see also Lopez ex rel. Gutierrez v. Premium Auto Acceptance Corp., 389 F.3d 504, 509 (5th Cir. 2004). A district court’s function when reviewing ERISA claims is like an appellate court’s.
“[The court] does not take evidence, but, rather, evaluates the reasonableness of an administrative determination in light of the record compiled before the plan fiduciary.” Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir.2002). Courts cannot consider additional evidence “resolve the merits of the coverage determination—i.e. whether coverage should have been afforded under the plan-unless the evidence is in the administrative record, relates to how the administrator has interpreted the plan in the past, or would assist the court in understanding medical terms and procedures.” Crosby v. La. Health Serv. & Indem. Co., — F.3d —, No. 10-30043, 2010 U.S. App. LEXIS 26323, *8, 2010 WL 5356498 (5th Cir. Dec. 29, 2010). A claimant is not permitted to explore, through discovery in an ERISA lawsuit, what information a plan administrator “should have considered” in making its benefits determination, as opposed to analyzing the information that the plan administrator “did consider” in making its decision. Griffin, 2005 U.S. Dist. LEXIS 18720, 2005 WL 4891214, at *2. (more…)
Category: 5th, Plan Language, Texas |
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