Posted By cmonfils on August 22, 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…)

Category: ERISA, Self-Funding, State Law | No Comments »
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Posted By cmonfils on August 22, 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…)

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Posted By cmonfils on August 22, 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…)

Category: ERISA, Legal, Self-Funding | No Comments »
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Posted By cmonfils on August 22, 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…)

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Posted By cmonfils on August 22, 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…)

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Posted By cmonfils on August 22, 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…)

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Posted By cmonfils on August 22, 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…)

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Posted By cmonfils on August 22, 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…)

Category: ERISA, PHI, Subrogation, Summary Plan Description | No Comments »
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Posted By cmonfils on August 22, 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…)

Category: Claims Review, DOL, External Claim Review, HHS, HIPAA, PPACA | No Comments »
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Posted By cmonfils on August 22, 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…)

Category: 9th, ERISA, Summary Plan Description, Supreme Court | No Comments »
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Posted By cmonfils on August 22, 2011

www.nytimes.com                  August 17, 2011 

By ROBERT PEAR 

WASHINGTON — The Obama administration proposed new rules on Wednesday that would require health insurance companies and employers to provide information to policyholders and employees describing health benefits, coverage and costs in plain English. 

Kathleen Sebelius, the secretary of health and human services, said the new “summary of benefits and coverage” would make it easier for consumers to shop for insurance and compare plans. (more…)

Category: Health Insurance, HHS | No Comments »
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Posted By cmonfils on 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…)

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Posted By cmonfils on August 22, 2011

www.eforerisa.com           August 14, 2011 

On August 12, 2011, a three-justice panel of the 11th Circuit Court of Appeals in Atlanta ruled that the PPACA’s individual mandate violated the Commerce Clause of the Constitution, which protects state commerce from federal regulation. In deeming the mandate to be unconstitutional, the 11th Circuit contradicted an earlier ruling in June by the 6th Circuit court in Cincinnati that upheld the measure. Now that two federal appeals courts have reached differing conclusions on the mandate, the issue may proceed to the Supreme Court, which begins a new term in October 2011. (more…)

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Posted By cmonfils on August 22, 2011

www.nytimes.com

By MICHAEL COOPER                 August 12, 2011 

The provision in President Obama’s health care law requiring Americans to buy health insurance or face tax penalties was ruled unconstitutional on Friday by the United States Court of Appeals for the 11th Circuit, in Atlanta. 

It was the first appellate review to find the provision unconstitutional — a previous federal appeals court upheld the law — and some lawyers said that the decision made it more likely that the fate of the health care law would ultimately be decided by the Supreme Court.  (more…)

Category: 11th, Georgia, Health Care Legislation, Health Insurance | No Comments »
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Posted By cmonfils on August 22, 2011

www.benefitspro.com               Heather Trese                August 19, 2011     

Health care reform is changing many things about the insurance industry, and in some cases those changes are not in the broker’s favor. But at least one area of the market is seeing a boon thanks to the Affordable Care Act — wellness plans. (more…)

Category: Health Care Legislation, Wellness | No Comments »
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