The Health Insurance Blog of Attorney Adam V. Russo
Welcome to Passion for Subro! The purpose of this site is to share my passion for the health insurance industry with the rest of you fanatics. I hope this site will be your destination for the latest in health care as well as self insured news across the country. While I envision that this site will serve as a great educational resource, it will also keep you entertained with the funny, difficult, confusing and just plain weird world of self insurance.
Thanks for visiting!
Posted By cmonfils on September 19, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
Legal Brief
A recent decision by a U.S. appeals court upheld a recovery in which a plan dealt directly with the auto liability insurer to achieve a recovery. The case is Shaffer v. Rawlings Co., 2011 WL 1977252 (6th Cir., May 18, 2011). (more…)
Posted By cmonfils on September 19, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
Legal Brief
Contrary to two recent decisions, a health plan in New York failed in its effort to intervene in a plan participant’s lawsuit against a third party, which would have let the plan in on settlement negotiations or made it a party to the court’s allocation of the settlement proceeds. A recent decision, Robles v. Bruhns, 2011 WL 1564649 (N.Y. Sup. Ct., Suffolk Cty., April 26, 2011), refused to allow such an intervention. (more…)
Posted By cmonfils on September 19, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
Legal Brief
We are familiar with cases holding that state laws limiting reimbursement to self-funded ERISA health plans from tort settlements or judgments through the madewhole, common-fund and collateral source rules are preempted by ERISA. However, we are not familiar with cases where there is a conflict between the right of a self-funded ERISA health plan to recover the benefits it paid under its plan provisions and the right of a hospital to recover its unpaid costs through a state statutory lien. We now have a case that discusses and resolves that conflict. The case is Osterman v. Smith, 2011 WL 1343056 (C.D. Ill., March 17, 2011). (more…)
Posted By cmonfils on September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
We’ve seen many cases where a self-funded ERISA health plan successfully recovers the benefits it paid from tort settlement proceeds, but we haven’t seen many cases where the plan also recovers its own attorney’s fees. American courts generally follow the practice that each party to a lawsuit bears the costs it incurs, whether it wins or loses the case. However, it’s not impossible for a successful litigant to recover its own legal fees from its unsuccessful opponent. (more…)
Posted By cmonfils on September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
In testimony before the House Subommittee on Oversight and Investigations on June 22, officials for the Centers for Medicare and Medicaid Services (CMS) defended how the Medicare Secondary Payer (MSP) program works, but GOP congressmen looked at billions of dollars of waste and gave CMS poor grades on tracking improper double payments. (more…)
Posted By cmonfils on September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
When a person is injured in an auto accident and is covered by both a health plan and auto liability insurance, the health plan usually pays its benefits first. That’s because the auto liability insurer has to determine that it has liability under its policy terms. However, in some cases, the auto liability insurer can establish its liability amount before a lawsuit or a trial to determine third-party liability. In those cases, the auto liability insurer is usually aware of the health plan’s right to reimbursement. Can it delay payment of its benefits until the health plan establishes its claim for reimbursement? That question arose in a recent decision involving Medicare. The case is Wilson v. State Farm Mutual Automobile Insurance Co., 2011 WL 2378109 (D.C. Ky., June 15, 2011). (more…)
Posted By cmonfils on September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
This case involved the right of a state Medicaid agency to recover the Medicaid benefits paid for two individuals injured by third parties. Under federal law, when a Medicaid recipient settles with a tortfeasor for an amount less than the full damages suffered, Medicaid’s share of the settlement may not exceed the portion of the settlement that represents the Medicaid participant’s medical expenses. The court in this case ruled that the program would be limited to recovering discounted charges actually paid, and not the amount billed. But the court refused to eliminate the agency’s lien against future medical expenses the participant might incur that will be paid by Medicaid. (more…)
Posted By cmonfils on September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
Just because a strategy to avoid reimbursing a health plan is unique does not mean it is going to prevent a plan from getting a full recovery. In one such case, attorneys argued against the plan getting relief based on a U.S. Supreme Court decision that federal courts have discretion to stay or dismiss an action based on considerations of “wise judicial administration, giving regard to conservation of judicial resources and comprehensive disposition of litigation.” (The ruling had nothing to do with health benefits). The court rejected this, finding no exceptional circumstances to warrant dismissal under that decision. In the other ruling, a participant tried to conceal the existence of a giant payoff but blundered spectacularly by enclosing a copy of $475,000 settlement check in a letter telling the plan that his client got only a $25,000 settlement. (more…)
Posted By cmonfils on September 16, 2011
Coordination of Benefits
Employee Benefits Series THOMPSON July 2011 | VOL. 19, No.3
By Jack B. Helitzer, Esq.
This issue of the Newsletter features a unique legal strategy used by a participant’s attorney who claimed that the auto liability insurer and the plan abused a plan member’s protected health information (PHI), when pursuing a subrogation claim. That approach raises the question of how plans can prevent subrogation situations from violating privacy laws. Well-drafted summary plan descriptions (SPDs) should include the plan’s privacy policies, including when PHI may be disclosed. One feasible approach may be for the plan’s subrogation and reimbursement provisions to cross-reference to the plan’s privacy provisions, and to have those provisions state that PHI can be shared with other insurers for benefits coordination. In addition, the plan’s privacy provisions should state that PHI may be disclosed to support a reimbursement claim. (more…)
Posted By cmonfils on September 16, 2011
The Self-Insurer August 2011
By Carolyn Smith, Esq. and John Hickman, Esq., Alston & Bird, LLP
New Claim Review Regulations Ease Compliance Burdens For Group Health Plans
On June 24, 2011, the U.S. Department of Treasury, Labor (DOL) and Health and Human Services (HHS) (collectively, the “Agencies”) jointly issued new interim final regulations (“Final Regulations”) and related guidance regarding the internal appeals and external claim review procedures (“Claims Review Rules”) for fully insured and self-funded group health plans and insurance policies issued in the individual market. These new requirements were added by the Affordable Care Act (ACA). The Claims Review Rules apply only to non-grandfathered group health plans otherwise subject to the health insurance reforms added by ACA. (more…)
Posted By cmonfils on September 16, 2011
The Self-Insurer August 2011
From the Bench Michael Friedman and John Eggertsen
The U.S. Supreme Court, in GIGNA Corp v. Amara, et al., 563 U.S., 2011 WL 1936077 (May 16, 2011), revisited, and likely expanded, the scope of equitable remedies available under ERISA § 502 (a)(3). The Court also rejected Plaintiff’s effort to sue under the terms of the SPD as opposed to the terms of the actual ERISA plan document. (more…)
Posted By cmonfils on September 16, 2011
Featured Health Business Daily Story, Sept. 13, 2011, and in Government News of the Week, Sept. 5, 2011
Reprinted from HEALTH PLAN WEEK, the most reliable source of objective business, financial and regulatory news of the health insurance industry.
By Jonathan Block, Editor – September 5, 2011 – Volume 21 Issue 31
Insurers have begun cutting commissions to agents and brokers in order to comply with the health reform law-mandated medical loss ratio (MLR) requirements that went into effect on Jan. 1, according to a Government Accountability Office (GAO) report released Aug. 29. And several agents and brokers interviewed by HPW say that their bottom lines have been squeezed as a result. (more…)
Posted By cmonfils on September 16, 2011
By Jessica Zigmond
Posted: September 14, 2011 – 11:15 am ET Insurance, Medicaid, Medicare
Building on the Medicare Recovery Audit Contractor program, HHS on Wednesday issued a final rule to establish a Medicaid Recovery Audit Contractor program (PDF) that the agency expects will save $2.1 billion in waste over the next five years. (more…)
Posted By cmonfils on September 16, 2011
www.smarthr.blogs.thompson.com
September 14, 2011 – 12:42 pm | By Todd Leeuwenburgh | No comments yet
Health care reform is still alive and kicking. Employer-sponsored health plans have implemented many of its thorny provisions, but one provision now looks like the biggest thorn of all.
We are talking about Section 2715 of the Patient Protection and Affordable Care Act (PPACA). You must, of course, know all about this section … no? Well, Section 2715 explains how employers and insurers are supposed to provide “Uniform Explanation of Coverage Documents.” (more…)
Posted By cmonfils on September 16, 2011
September 13, 2011 By Jenny Ivy
A federal judge in Pennsylvania ruled Tuesday the requirement imposed by federal health reform that individuals must buy health insurance or pay a penalty is unconstitutional.
U.S. District Judge Christopher C. Conner in Harrisburg declared the minimum coverage provision of the Patient Protection and Affordable Care Act exceeds Congress’s authority under the U.S. Constitution. (more…)
