cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
Sponsors and administrators of employer-sponsored health plans will spend lots of 2012 in implementing the health reform law, because there’s still a lot of uncertainty that will decide the fate of self-funded health plans in particular. Plans will have to raise annual limits on essential benefits (as defined by reform rules) to $2 million starting next Sept. 23. Plans won’t have to pay new fees to fund comparative effectiveness research in 2012. But 2012 will be the year plans learn the payment frequency of and the method used to calculate the fees they will start paying in 2013. Similarly, plans won’t have to start issuing summaries of benefits and coverage (SBCs) to all participants, but they will be waiting and watching for rules about the SBC to develop, so they know how to satisfy that requirement. (more…)
Category: Accountable Care Organizations, DOL, Health Care Legislation, HHS, Medicare, Plan Sponsor, PPACA, PPOs, Third Party Administrators |
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cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
By Adam V. Russo & Ron Peck
As avid readers of this article are aware, every month we write from the perspective of a self-funded plan, address how the health insurance industry should work, and what needs to be done to lower the cost of health care. Generally, we represent self-funded benefit plans and their third party claims administrators (“TPAs”). You may also know, specifically, that we have been spending a lot of our time dealing with conflicts that arise between these benefit plans and the health care service providers (“Providers”) that treat the plan participants. In this article, we want to look at these issues from the Providers’ perspective. You may be surprised by the differences in opinion regarding the value of preferred provider organizations (“PPOs”), and more shockingly, our common ground. (more…)
Category: Balance Billing, PPOs, Usual and Customary |
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cmonfils | December 13, 2011
PepsiCo Inc. employees across the country can get free travel to Johns Hopkins Hospital for surgeries under a new benefit the soda giant is now offering.
http://www.bizjournals.com/baltimore/news/2011/12/08/pepsi-offers-workers-benefit-of.html
Category: Plan Documents, PPOs |
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cmonfils | December 2, 2011
Dear Colleagues and Friends:
The line between claims processor and payor of claims has been blurred… and you may be at risk.
The Phia Group has often advised you regarding why it is in your best interest, as TPAs, to avoid signing PPO network agreements that identify you as a payor. Other TPAs are now dealing with the repercussions of this exact issue. TPAs are being sued by providers. Providers are pursuing TPAs for payment of medical claims. Courts are deciding that TPAs are responsible for payment. Startlingly, this is happening with greater frequency.
Yet, we understand that market realities require you to secure access to network discounts for your clients.
If you are a TPA that has signed a PPO agreement, and you do not have a joinder agreement executed by the Plan Administrator and PPO that unambiguously shifts payment responsibility from you to the Plan Administrator, please contact me or Adam Russo without delay. Adam can be reached at arusso@phiagroup.com or 781-535-5622. I can be reached using the contact information below.
Best regards,
Ron E. Peck, Esq.
Sr. Vice President & General Counsel
The Phia Group, LLC
163 Bay State Drive
Braintree, MA 02184
Phone: 781-535-5617
Fax: 781-535-5656
Category: PPOs, Third Party Administrators |
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cmonfils | November 7, 2011
By Adam Russo, Esq., The Phia Group
Imagine being prohibited from reviewing your credit card statement or restaurant check prior to paying your bill. Imagine if you were offered a discount, but were not allowed to review your bills for any charges that were not yours, or perhaps seemed a bit expensive. What would you do if upon entering the supermarket, you were offered a 20% discount on your entire purchase but were not allowed to review your final bill? The deal you were accepting, by its terms, would deny you the ability to ensure that none of your items were scanned twice, or that your coupons were applied. How many of you would accept the 20% discount if you were not allowed to audit this bill? I have posed this very question to audiences at various conferences across the country; approximately half of those asked said that they would accept this offer. This is the same dilemma we face in the self funded industry when it comes to dealing with preferred provider organizations (PPOs). (more…)
Category: PPOs |
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cmonfils | May 16, 2011
www.myhealthguide.com
MyHealthGuide Source: Todd Leeuwenburgh, Editor, Employer Health Benefits, Thompson Publishing Group, 5/10/2011, www.thompson.com
Case: Montefiore Medical Center v. Teamsters Local 272, 2011 WL 1498823 (2nd Cir., 4/21/2011
A health provider argued that an otherwise valid assignment of benefits is a “nullity” whenever care is provided in-network. While novel, the health provider’s approach was unsuccessful in trying to avoid ERISA preemption of its state-law claims against an employer plan. (more…)
Category: 2nd, ERISA, PPOs |
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cmonfils | May 5, 2011
Please click the attached link…
Category: PPOs |
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cmonfils | April 20, 2011
Robyn Jacobson of Entrust, Inc.
Late last night, Rep. Eiland made progress persuading Rep. Taylor (our advocate) that his bill needed to be passed without any amendment exempting TPAs/Employers. Apparently, this is the “only bill that TMA is really pushing this session” and “passage would be an unfair competitive advantage for TPA’s”. (more…)
Category: PPOs, Texas, Transparency |
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cmonfils | April 20, 2011
The Phia Group
INTRODUCTION
Texas HB 1534 is an attempt to regulate “silent PPO’s” and access to certain discounted arrangements with potentially significant financial consequences should there be a finding by the Commission that discounts were unlawfully taken.
More to the point, the bill regulates any entity (including third party administrators and employers) that contract directly with a provider for the delivery of health care services; (see TPAs and benefit plans that contract with providers, TPAs and benefit plans that agree to have a PPO act as their agent and negotiate with providers in the TPA / Plan’s name, and/or PPOs themselves). (more…)
Category: PPOs, Texas, Transparency |
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cmonfils | April 8, 2011
www.latimes.com
By Duke Helfand April 3, 2011, 3:13 a.m.
Thousands of employers in California and across the country are slashing expensive doctors and hospitals from their insurance rosters in a move to hold down rising healthcare costs — a trend that is gaining favor with corporate bosses, if not the rank and file. (more…)
Category: California, PPOs |
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cmonfils | January 27, 2011
I have just received this information from a TPA client. Please check out the bolded language on how PPO’s are trying to dictate plan terms and claims process.
Eligibility Verification. Client shall maintain during normal business hours a procedure for prompt verification of a Covered Person’s enrollment in a Benefit Plan. Client will use best efforts to provide current eligibility/compensability information to Contract Providers. Notwithstanding, the parties agree that: (a) verification of eligibility is not a guarantee of benefits and (b) benefits for Covered Services shall be paid in accordance with the provisions of the applicable Benefit Plan. Client agrees that after confirmation by Contract Provider of a Covered Person’s eligibility, Client may not deny payment for Covered Services performed under the terms of this Agreement which are medically necessary.
Category: PPOs |
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