cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
In a lawsuit involving denied gastric repair services, a third-party administrator (TPA) argued its way out of an ERISA claim for denied benefits and alleging fiduciary abuse, after the court agreed it only did what the plan sponsor told it in documents, e-mails and conversations.
The plaintiff accused the TPA of being a de facto plan administrator, in spite of the fact the plan document expressly disavowed any fiduciary role for the TPA. (more…)
Category: 10th, ERISA, Fiduciary, Third Party Administrators |
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cmonfils | December 22, 2011
December 22, 2011 — The Self-Insurance Institute of America, Inc. (SIIA) today announced that it has filed a complaint in Federal Court requesting a declaration that Michigan’s recently passed Health Insurance Claims Assessment Act is preempted by the Employee Retirement Income Security Act (ERISA). SIIA also seeks an injunction against implementation and enforcement of the Act involving self-insured group health plans that are subject to ERISA or their business partners. (more…)
Category: ERISA, Michigan, Third Party Administrators |
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cmonfils | December 21, 2011
www.siia.org
December 15, 2011 – The Self-Insurance Institute of America, Inc. (SIIA) today filed an “initial” amicus brief with the Texas State Supreme Court in the case of GPA Holdings, Inc. v. Baylor Health Care Systems. This initial brief supports GPA’s request that the Supreme Court consider arguments to reverse an adverse judgment issued by the Fifth District Court of Appeals. Should the Court agree to hear arguments, SIIA will file a secondary, more comprehensive brief. (more…)
Category: ERISA, News, Self-Funding, Third Party Administrators |
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cmonfils | December 16, 2011
The Self-Insurer November 2011 Issue & Volume 37
By: John Hickman, Esq., Alston & Bird, LLP
New Fees for Group Health Plans Loom on the Horizon
The Affordable Care Act (ACA or the “Act”) imposes two new temporary fees with respect to group health plans that go into effect in the near future:
- A Fee to fund comparative effectiveness research that, in the case of calendar year plan years, it is first due for plan years starting on or after January 1, 2012, and
- Starting in 2014, a “contribution” in an amount to be determined by the Department of Health and Human Services (HHS) and collected at the state level that is part of the temporary reinsurance program established under ACA to help ensure the financial stability of the individual insurance market as further reforms go into effect (including the guaranteed issue requirement) and the Affordable Insurance Exchanges (“Exchanges”0 become operational. (more…)
Category: Health Care Legislation, Health Insurance, HHS, HIPAA, PPACA, Third Party Administrators |
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cmonfils | December 5, 2011
www.myhealthguide.com
MyHealthGuide Source: Thomas Croft, Esq., King & Croft LLP, 12/2/2011, www.StopLossLaw.com
Case: Hebrew Home of Greater Washington, Inc. v. CoreSource, Inc. and Sun Life Assurance Co. of Canada; No.11-cv-00710, in the United States District Court for the District of Maryland, 11/3/2011. Court’s Opinion
Mr. Croft’s Comment: A Maryland federal court has determined that a self-insured group’s claims against its TPA are only partially pre-empted by ERISA and that a payment outside a stop loss policy’s run-out period is ineffective to trigger coverage, despite a claim that the payment “substantially complied” with the policy’s terms. (more…)
Category: ERISA, Self-Funding, Stop Loss, Third Party Administrators |
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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 29, 2011
www.myhealthguide.com
MyHealthGuide Source: Allison Bell, 11/21/2011, LifeHealthPro Article
Karin James, an assistant vice president in the U.S. stop-loss operations at Sun Life Financial Inc., Toronto (NYSE:TSX), says, “Stop-loss is a very tough market. Very competitive.” during a recent interview.
The Patient Protection and Affordable Care Act of 2010 (PPACA) has increased interest in stop-loss for employers to give self-funding and stop-loss a new look by exempting self-funded plans from many of the new PPACA mandates. (more…)
Category: PPACA, Self-Funding, Stop Loss, Third Party Administrators |
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cmonfils | November 18, 2011
Massachusetts has recently finalized regulations requiring third party administrators to register with the Commonwealth as well as file annual reports. This will likely affect many TPAs in Massachusetts because the definition of TPA is broad:
Third-party Administrator: A person domiciled inside or outside of the Commonwealth who, on behalf of a Health Insurer or purchaser of health benefits, receives or collects charges, contributions or premiums for, or adjusts or settles claims on or for residents of the Commonwealth. Third-party Administrator shall also include pharmacy benefit managers and any other entity with claims data, eligibility data, provider files and other information relating to health care provided to residents of the Commonwealth and health care provided by health care providers in the Commonwealth, except that Third-party Administrator shall not include an entity that administers only claims data, eligibility data, provider files and other information for its own employees and dependents. (Emphasis added.) 211 C.M.R. 148
These new regulations amend the proposed regulations issued in February which originally excluded from the definition of third-party administrator an “entity with claims data, eligibility data, provider files and other information relating to health care provided to residents of the Commonwealth and health care provided by health care providers in the Commonwealth.”
The hearing for the regulations was March 16, 2011 and the regulations became effective May 27, 2011. The Division of Insurance posted the updated regulations as well as the application and annual report information on its website in June. This is the link to the application and the annual report: http://www.mass.gov/ocabr/licensee/license-types/insurance/third-party-administrators/.
Category: Massachusetts, Third Party Administrators |
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cmonfils | October 26, 2011
Third party administrators (TPAs) are struggling to determine if and how the new service provider fee disclosure regulations will affect their practices. Many TPAs have determined that they are not subject to the disclosure requirements because they receive their compensation directly from the employer or from the plan. TPAs that have made such determinations may, nevertheless, have concerns because they may receive unanticipated indirect payments from financial institutions to which they refer business. In this technical update, we will discuss how a TPA deals with unanticipated indirect compensation.
Category: Third Party Administrators |
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cmonfils | September 26, 2011
www.myhealthguide.com
MyHealthGuide Source: Jerry Geisel, 9/20/2011, Business Insurance Article – Michigan
LANSING, MI — Michigan Governor Rick Snyder on Tuesday signed into law legislation, S.B. 348, that will impose a new 1% tax on paid health care claims.
The tax will be paid starting Jan. 1, 2012, by insurers that provide fully insured plans and by third-party claims administrators in the case of self-funded plans. (more…)
Category: Michigan, Self-Funding, Third Party Administrators |
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cmonfils | September 19, 2011
www.myhealthguide.com
MyHealthGuide Source: Sherlock Expense Evaluation Report (SEER) via Business Wire, 9/7/2011, www.sherlockco.com
PHILADELPHIA — Administrative expenses for core services of selected TPAs were 98% of fees in 2010. This was $18.72 per employee per month (PEPM) or $8.08 per member per month (PMPM). Core Medical product costs were $22.15 PEPM and $10.56 PMPM. (more…)
Category: Third Party Administrators |
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cmonfils | August 22, 2011
www.spbatpa.org
by Frederick D. Hunt, Jr. SPBA President
About 55% of U.S. workers with non-federal health & pension employee benefits are in plans using some degree of Third Party Administration (TPA). A 2003 survey by Fidelity Employer Services Co. found that 91% of employers outsource their health & insurance to a third party. 30% do so “completely” and 61% partially. A 2002 survey of employers that have in-house benefits managers reports that 79% of employers use TPAs. Those number seem too high, but about 5/6 of the market for comprehensive TPA services to health plans use SPBA Member TPAs. Who are these TPAs and what do they do? This paragraph should warn you that statistics about employee benefits vary widely! (more…)
Category: Third Party Administrators |
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cmonfils | August 7, 2011
The Self-Insurer July 2011 From the Bench Thomas A. Croft, Esq.
One of the “real world” things I have learned in this business is that many TPAs believe that, once a claim has reached the specific deductible on a stop loss policy, it becomes the stop loss carrier’s problem. And many MGUs and carriers seem to behave as if this mistaken assumption is true. The result is that MGUs/carriers are tempted to become too involved in the ongoing management of a claim while TPAs are tempted to shirk their responsibilities to their client and “delegate” upstream their responsibilities to the MGU/carriers. Succumbing to either of these temptations is legally inappropriate. (more…)
Category: Stop Loss, Third Party Administrators |
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cmonfils | August 2, 2011
www.myhealthguide.com
MyHealthGuide Source: Christine P. Roberts, Mullen & Henzell L.L.P. 7/24/2011, E is for ERISA
Since 1989, failures to comply with the continuation coverage requirements of COBRA have potentially triggered excise taxes under IRC § 4980B on those responsible for the error, equal to $100 per affected person, per day. However the Internal Revenue Service rarely imposed and collected the tax and there previously has been no affirmative duty on taxpayers to report or pay it. (more…)
Category: News, Third Party Administrators |
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cmonfils | July 25, 2011
www.myheat;hguide.com
MyHealthGuide Source: Thomas Croft, Esq., King & Croft LLP, 7/20/2011, www.StopLossLaw.com
Case: Woodruff & Sons, Inc. v. The Covenant Services Group, Inc., No. 8:11-cv-1096, in the United States District Court for the Middle District of Florida, July 12, 2011). Court’s Opinion
Mr. Croft’s Comment: This state law based case was filed against a TPA for allegedly failing to meet a stop loss policy deadline for the filing of an aggregate claim, with the result that the claim was denied. The defendant TPA moved to dismiss the Complaint against it, arguing that ERISA pre-empted the group’s state law claims. (more…)
Category: ERISA, Stop Loss, Third Party Administrators |
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