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…)
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…)
cmonfils | April 19, 2011
In Quintana v. Lightner, the Plan participant is suing State Farm and Ingenix for violations of his right to privacy, conspiracy to invade privacy, HIPAA violations, and intentional infliction of emotional distress. Ingenix provided State Farm with an itemization of Quintana’s medical bills, which included the dates of service, provider, diagnosis code, etc. Quintana asserts, among other things, that in providing State Farm with the itemization, Ingenix might adversely affect the outcome of his suit against state Farm’s insured. (more…)
cmonfils | April 19, 2011
Legislative Alert – HB 1534 by Rep. Craig Eiland
HB 1534 is the PPO bill from last session (HB223) that Rep. Eiland and TMA tried to make TPA’s subject to. This is an onerous bill that would significantly affect our industry. TPA’s and self-funded employers have not been exempted as we originally thought and worked toward. (more…)
cmonfils | April 12, 2011
Texas recently introduced a bill allowing recovery of attorney’s fees by a prevailing party when a trier of fact determines there has been an “abusive civil action”. An attorney may be held jointly and severally liable for litigation costs awarded, if they have a financial interest in the action. Financial Interest is defined as an attorney’s compensation for services being contingent in whole or in part on the outcome of the action. This bill would only apply when the amount in controversy is or exceeds $100,000.00. Worker’s compensation claims are excluded from the bill.
Thanks to William T. Sebesta, an attorney with Doyen Sebesta in Houston, Texas, for identifying this bill.
cmonfils | April 12, 2011
Robyn M. Jacobson — 2010-2011 President, Texas Association of Benefit Adminsitrators
In short, this bill requires all plans (except ERISA plans) to cover any expenses incurred as a by-product of intoxication or narcotics. This also applies to Chapter 172 plans (non-ERISA self-funded plans) and Lloyd’s plans under Chapter 941. Along with many other bills, it is up for a hearing tomorrow. (more…)
cmonfils | January 12, 2011
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…)
Adam V. Russo | June 28, 2010
Twenty states so far have rejected federal funds to administer a high-risk insurance pool, as designed by the Patient Protection and Affordable Care Act. The high-risk pool would extend coverage to state residents unable to purchase insurance because of preexisting medical conditions. In these states, the federal government will be responsible for creating and running a high-risk pool on behalf of the state, as mandated by the Affordable Care Act. The 20 states are: Alabama, Arizona, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, North Dakota, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Wyoming. Two states, Oregon and Utah, have not indicated whether they will be running their own high-risk pool or if they will let the HHS run it for them. The remaining 28 states have decided they will run their own temporary high-risk pool. For more information, visit http://www.hhs.gov/ociio/initiative/hi_risk_pool_facts.html. (more…)
Adam V. Russo | June 17, 2010
Texas Health Insurance Risk Pool v. Sigmundik, 2010 WL 2136625 (Tex. 2010)
The self insured industry got a big subrogation win. In a very pro-subrogation opinion, the Texas Supreme Court declared that a trial court abuses its discretion when it invokes the equitable “Made Whole” Doctrine to circumvent a party’s contractual right to subrogation. The Court went even further and said that a trial court may not cut a party out of a settlement where the settlement purports to resolve that party’s claim, and the party participated in the proceedings and requested an allocation.
Adam V. Russo | June 15, 2010
As you know, the recent Fortis case in Texas said that if a plan document excludes made whole rule (and presumably, other equitable doctrine such as the common fund doctrine), the contract language trumps the equitable doctrine.
The Texas Supreme Court recently struck another big victory for subrogation in its Health Insurance Risk Pool v. Sigmundik, 2010 WL 2136625 (Tex. 2010), case. In a powerful, pro-subrogation opinion, the Court declared that a trial court abuses its discretion when it invokes the equitable doctrine to circumvent a party’s contractual right to subrogation.
Basically, under Texas State law, if the plan language says made whole doesn’t apply… it doesn’t apply! We also feel strongly that these cases can be used to counter common fund arguments as well.
Adam V. Russo | June 7, 2010
MyHealthGuide Source: StreetInsider.com, 6/2/2010,
AUSTIN, TX — The Texas Supreme Court has declined to review a case involving the amount some hospitals marked up workers’ compensation-related bills under rules in effect until 2008.
“Texas employers realized a great victory today,” Mary Barrow Nichols, general counsel and senior vice president for Texas Mutual, said. “A small number of hospitals were marking up a $4,000 item to $40,000 or more, or they’d turn a two-day admission into a $120,000 bill. These inflated charges could have cost the system hundreds of millions of dollars and continued to affect the workers’ compensation premiums of every Texas employer.” (more…)
Adam V. Russo | May 21, 2010
By TODD ACKERMAN HOUSTON CHRONICLE
Texas doctors are opting out of Medicare at alarming rates, frustrated by reimbursement cuts they say make participation in government-funded care of seniors unaffordable.
Two years after a survey found nearly half of Texas doctors weren’t taking some new Medicare patients, new data shows 100 to 200 a year are now ending all involvement with the program. Before 2007, the number of doctors opting out averaged less than a handful a year. (more…)
Adam V. Russo | May 21, 2010
by Emily Ramshaw
Prudie Orr is a licensed psychiatric nurse practitioner, but these days she feels more like an aspiring indentured servant. Since moving to the Central Texas town of Georgetown in December, she’s been unable to open a practice and see patients — because she can’t find a doctor who will allow it. “I’ve gone up and down the telephone book, calling every psychiatrist in town,” she says. “I have to go hat in hand to these folks to see if they will grant me the privilege of making a living.” (more…)
Adam V. Russo | April 6, 2010
By DAVE MICHAELS / The Dallas Morning News
WASHINGTON – The landmark health care law approved this week was sold as an effort to reform unfair insurance practices, but it largely exempts the existing employer-based network from the overhaul.
The law grandfathers many existing employer-sponsored plans, sparing them from the consumer protections that will apply to new plans, including minimum-benefit standards and limits on how much a worker can pay in out-of-pocket medical costs. (more…)
