MyHealthGuide Newsletter
News for the Self-Funded Community
10/27/2014

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TABLE OF CONTENTS

 

General & Company News

People News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures


General & Company News



Symetra's President and CEO Tom Marra on A.M.BestTV: Medical Stop-Loss 'Sweet Spot'

MyHealthGuide Source: 10/23/2014, A.M. BestTV Video

OLDWICK -- In this A.M.BestTV episode, Tom Marra, president and chief executive officer at Symetra Financial (Symetra), examines how the medical stop-loss insurance for employers that self-insure their employees' health benefits has emerged as a growth area.

Marra said his company's strategy is to be a national player in each of the company's three divisions: life insurance, retirement and employee benefits. He also notes that medical stop-loss continues to be at the core of Symetra's benefits division.

"Symetra has been in the medical stop-loss insurance industry for more than 40 years; thus, we have expertise that has built up steadily. Since the medical stop-loss product is a pure insurance, its risk dynamics are good," said Marra.

Marra addresses how medical stop-loss gets a lot of coverage, but also competition. "Symetra, along with four or five companies, dominate this industry," said Marra. "And due to the product being typically sold by the largest brokers, it is a niche product that is tied to a core benefit strategy, which gives it a lot of coverage."

Marra discusses the opportunities that the post health reform era has created for the industry. He said, "One opportunity is that most employers in the 500 to 2,000 'sweet spot' for medical stop-loss will look at all their options and going self-insured is one of them, and whenever a company becomes self-insured it covers catastrophic claims that might emerge. Hence, the company needs medical stop-loss coverage."

About A.M. Best

A.M. Best Company is the world's oldest and most authoritative insurance rating and information source. Visit www.AMBest.com.

About Symetra

Symetra Life Insurance Company is a subsidiary of Symetra Financial Corporation (NYSE: SYA), a diversified financial services company based in Bellevue, Wash. In business since 1957, Symetra provides employee benefits, annuities and life insurance through a national network of benefit consultants, financial institutions, and independent agents and advisors.  Visit www.symetra.com

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Teladoc Adds Senator William Frist, M.D. and David Snow to Board of Directors

MyHealthGuide Source: Teladoc, Inc., 10/21/2014, www.Teladoc.com

DALLAS -- With the expansion of health insurance to an estimated 8 million new patients through the Affordable Care Act, innovations are needed to meet the primary care needs of all Americans. Dallas-based Teladoc, the nation's largest telehealth provider, has proven that telemedicine is an exceptional way to deliver high-quality, cost effective care.

Underscoring its industry leadership, Teladoc CEO Jason Gorevic announced the addition of two preeminent health care leaders to the company's board of directors: former U.S. Senator William Frist, M.D. and former Medco Health Solutions chairman and CEO David B. Snow.

"Senator Frist and David Snow are ideal Teladoc board members. These men have successfully navigated the complexities of Wall Street and the halls of Congress. Their commitment to Teladoc brings an added level of experience and success that will be invaluable to us as we continue our explosive growth and navigate the changing landscape of health care," said Gorevic. "Both Senator Frist and Dave Snow have numerous opportunities to sit on boards and they chose Teladoc. Their joining our board is not only an endorsement of Teladoc, but also of the telehealth industry."

Senator Frist is a world-renowned cardiothoracic transplant surgeon and a leading authority on health care policy. During his tenure on Capitol Hill, he served on both the Health and Finance Committees, where he was instrumental in passing health care reform legislation and ultimately served as Senate Majority Leader. Senator Frist brings to Teladoc decades of experience in providing top quality patient care, driving health care policy and reform, and a reputation for championing innovations that deliver improved health care outcomes.

"The implementation of the Affordable Care Act has infused an additional 8 million patients into the health care system, and this number is expected to grow significantly in the coming years. The increased demand will further tax our already overburdened primary care system, resulting in even longer patient wait times," said Senator Frist. "Teladoc is an innovative and effective solution for addressing the current access barriers to primary care. The Teladoc model has shown what we have believed to be true: that many of the everyday health care needs of patients can safely and efficiently addressed remotely using technology. It is exactly the type progressive and forward-thinking company we need in the health care industry today. As a Teladoc board member, I want to ensure our country's legislative groups understand the benefits Teladoc can bring to the health care system as a whole, but most specifically, the need it fills for the patients it serves."

David B. Snow, Jr., is a health care industry veteran, innovator and entrepreneur who has created and implemented solutions to manage the rising costs of health care. Most recently, he served as the chairman and chief executive officer of Medco Health Solutions, one of the nation's largest pharmacy benefit managers. Under his leadership, Medco's revenue grew from $34 billion to more than $70 billion. Prior to joining Medco, he served as president and chief operating officer at Empire BlueCross BlueShield. Currently, Snow serves as the chairman and CEO of Cedar Gate Technologies, a health care information technology data analytics company.

"There is a clear need in our country to create greater access to physicians. Teladoc is a change agent for the way consumers want to access primary care," said Snow. "As more and more companies look for efficient and cost-effective means for providing health care to their employees, telehealth -- and Teladoc -- are critical to fixing what is broken within our health care system today. Teladoc's outstanding technology, scalable business model and phenomenal year-over-year growth is evidence of the value it brings to its members and clients. The company's growth continues to be strong and I look forward to helping Teladoc accelerate its growth trajectory."

Teladoc recently announced it secured $50 million in funding, one of the single largest investments in a telehealth company. "Teladoc is in a significant position of strength; we have outstanding growth momentum, stellar leadership and we are financially strong. The
combination of the infusion of capital and addition of these industry icons to our board of directors will accelerate our growth strategy and further cement our foothold as the dominant leader in telehealth," added Gorevic.

About Teladoc

Founded in 2002, Teladoc is the nation's leading telehealth provider with 8 million members and more than 250,000 consults annually. Teladoc provides 24/7 access to affordable, high-quality medical care for adults and children experiencing non-emergency medical issues via phone, secure online video, mobile app or HealthSpot™ Station -- a private, walk-in kiosk. Through a directly-managed network of U.S.-based, board-certified physicians, Teladoc delivers a 95 percent patient satisfaction rate with an average response time of 16 minutes. Teladoc is the first and only telehealth provider to receive certification from the National Committee for Quality Assurance (NCQA) for its physician credentialing process, scoring 100 percent. Recognized by Fast Company as "One of World's Most Innovative Companies in Health Care" in 2013, Teladoc partners with health plans, corporations, organizations and patients that seek accessible and affordable high-quality medical care. Contact Bill Fryling, Director of Sales, at (704) 776-6106, bfryling@teladoc.com and visit www.Teladoc.com.

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QBE North America names William Kronenberg III to Board of Directors

MyHealthGuide Source: QBE North America, 10/23/2014, www.qbena.com

New York, NY -- QBE North America has announced the appointment of William Kronenberg III to its Board of Directors. With nearly 40 years of experience in the insurance industry, Kronenberg is well suited to assist in enhancing QBE’s North America results.

"We’re proud to have someone of Bill’s caliber join the Board. We look forward to drawing on his keen understanding of the Property & Casualty market, leadership experience in a global insurance organization, and extensive knowledge of the Specialty and Program business models in the US as we continue to transform QBE North America," says Dave Duclos, President and CEO.

Kronenberg currently serves as the principal owner of Fresh Start Development Co., LLC and is a director of Glatfelter Insurance Group. Previously, Kronenberg served as CEO and principal owner of Professional Underwriters, a program administrator specializing in the Public Entity market segment that was acquired by Glatfelter Insurance Group in 2008. From 1999 to 2002, Kronenberg served as CEO of XL Environmental, Inc. (formerly ESCS) and as a Director of XL America, Inc. Until its acquisition in 1999 by XL Capital, Kronenberg served as owner, CEO and President of ECS, Inc. a company specializing in integrated environmental risk management solutions. Kronenberg’s early insurance career began with AIG, including several casualty-oriented underwriting positions, concluding as the officer in charge of AIG’s program unit.

About QBE

QBE North America is part of QBE Insurance Group Limited, one of the largest insurers and reinsurers worldwide. QBE NA reported Gross Written Premiums in 2013 of $5.855 billion. QBE Insurance Group’s 2013 results can be found at www.qbena.com. Headquartered in Sydney, Australia, QBE operates out of 43 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New York, conducts business through its property and casualty insurance subsidiaries. QBE insurance companies are rated "A" (Excellent) by A.M. Best and "A+" by Standard & Poor’s.  Contact Deidra Parrish Williams, V.P., US Communications, at 212.805.9750 Ext: 828750, Deidra.ParrishWilliams@us.qbe.com and visit www.qbena.com.

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One Call Adds Greg Roth To Board of Directors

MyHealthGuide Source: One Call Care Management (One Call), 10/14/2014, www.onecallcm.com

JACKSONVILLE, FL -- One Call Care Management (One Call), the nation's leading provider of specialized services that add value throughout the continuum of workers' compensation care, has named healthcare executive Greg Roth to its Board of Directors.

"Greg's experience as a leader and innovator in healthcare will be a tremendous asset to One Call's Board of Directors and to our leadership team," stated Buddy Gumina, Partner with Apax Partners and Chairman of One Call Care Management.

"As One Call moves forward in its mission to improve workers' compensation outcomes by delivering market-leading specialty services, innovative leakage capture solutions, and enhancing efficiencies across the continuum of care, Greg's insights and leadership will be a welcome addition," commented Joe Delaney, President and CEO of One Call.

"One Call brings an inspiring vision to workers' compensation combined with the commitment to deliver on what customers need today while innovating for their needs tomorrow," observed Mr. Roth. "It is the first and only company to bring together the industry's top experts in specialty services across the continuum of care, along with the financial strength and stability to truly transform workers' compensation results. I look forward to being a part of One Call's journey toward that vision."

Mr. Roth's career spans three decades of introducing innovation to transform and improve healthcare. Most recently he spent 10 years with TeamHealth, a leading national healthcare company offering permanent outsourced physician staffing solutions for 860 healthcare companies in 46 states. At TeamHealth, Mr. Roth held the positions of Chief Executive Officer, President and Chief Operating Officer, and also served as a member of the Board.

Previously, Mr. Roth served as an executive for HCA - Hospital Corporation of America for 10 years as President of the Ambulatory Surgery Division, Senior Vice President of Operations for the Western Region, and the Division's Chief Financial Officer.

Prior to these leadership roles, Mr. Roth held a variety of financial and operational positions in the healthcare industry. He holds a Master's Degree in Health and Hospital Administration from Xavier University and a B.S. in Allied Health Professions from Ohio State University. He is a Certified Public Account (CPA) and a Registered Respiratory Therapist.

About One Call Care Management

One Call Care Management (One Call) is the nation's leading provider of specialized solutions to the workers' compensation industry. One Call's solutions enable faster, more efficient and more cost-effective claims resolution. One Call provides reliable, consistent connections to care with expertise in high end diagnostics, physical therapy and transportation services, post-discharge home care and durable medical equipment, dental and doctor specialty services, complex care management, and the language services required for today's multicultural workforce. With a focus on injured workers' needs across the continuum of care, One Call enables maximum medical improvement and superior outcomes. Visit www.onecallcm.com.

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People News



HM Insurance Group Names Mark Nave as SVP, Strategy & Marketing

MyHealthGuide Source: HM Insurance Group, 10/23/2014, www.hmig.com

PITTSBURGH -- Mark Nave has joined HM Insurance Group (HM) as senior vice president, strategy & marketing. Mark follows Matt Rhenish, who was named president & COO of the company earlier this year. In his role, Mark will lead strategic planning, product development, market research, marketing and communications, events, project management and business analytics for HM.

"We are excited to have Mark on the leadership team at HM," Rhenish said. "With his strong background in strategic development and business transformations, he brings excellent business analysis and problem-solving capabilities that can build on our success."

Mark comes to HM from the management consulting firm McKinsey & Company, where he most recently held the role of engagement manager. There he led teams of consultants and worked with leading organizations from the health and financial services sectors on solving their toughest problems and developing practical solutions. Prior to McKinsey & Company, Mark held various leadership roles in sales, marketing and product management in the high tech sector -- specifically with RF Micro Devices and Robert Bosch GmbH. He also served as a Naval Flight Officer in the United States Navy and deployed to various duty stations around the world.

Mark received his MBA from the University of Maryland, after earning a bachelor’s degree in Systems Engineering from the United States Naval Academy.

Headquartered in Pittsburgh, HM Insurance Group is a recognized leader in risk management. HM's product portfolio features employer stop loss and managed care reinsurance. The company also offers workers' compensation in Pennsylvania.

About HM Life Insurance

HM Life Insurance Company, HM Life Insurance Company of New York, HM Casualty Insurance Company and Highmark Casualty Insurance Company have "A-" (Excellent) ratings from A.M. Best Company. Through its insurance companies, HM Insurance Group holds insurance licenses in 50 states and the District of Columbia and maintains 23 regional sales offices across the country. Visit www.hmig.com.

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Athens Administrators Expands Program Insurance Market Focus, Names Executive Vice Presidents Raffy Daghlian And Guy Mastrangelo

MyHealthGuide Source: PRNewswire, 10/20/2014, www.athensadmin.com

CONCORD, CA -- Athens Administrators, a third-party claims administration services provider since 1976, has actively participated in the Program Insurance market segment on a regional basis for several years. Program Insurance is a critical area of focus for Athens and a unique segment for TPAs, requiring a highly specialized approach. To lead Athens' efforts in the Program Insurance space, we are proud to announce the appointment of Raffy Daghlian and Guy Mastrangelo as executive vice presidents. Both will continue to operate from the East Coast, and will be critical components of our continued expansion throughout the U.S.

In recent years Athens has achieved significant growth, delivering the highest-quality claims administration services. The addition of industry veterans Raffy Daghlian and Guy Mastrangelo will aid our continual expansion and help us provide outstanding Program Insurance services. Both executives bring a unique and valuable set of skills to the company, with a tremendous level of hands-on expertise in the Program Insurance claim administration space.

Athens' success is predicated on exceptional claims service and high-quality data and information from the TPA. We are proud to include Raffy and Guy on our industry-leading team. With over 50 years of combined experience in the claims and commercial insurance arena, they will lead the company's Program Insurance initiatives, and provide account management services for our valued program partners and clients.

About Athens

Athens is a privately held company that provides property and casualty workers' compensation claims administration and managed care services. We are accustomed to operating in the most complex insurance markets. Our clients include managing general agencies, insurance carriers, retail insurance brokers, private and public sector self-insured entities, high-deductible captives and self-insured groups. Visit www.athensadmin.com.

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United Claim Solutions (UCS) Welcomes Tobey Busch to its Information Technology Department

MyHealthGuide Source: United Claim Solutions (UCS), 10/24/2014, www.unitedclaimsolutions.com.

PHOENIX, AZ -- United Claim Solutions (UCS), an innovative Medical Cost Reduction and Claims Flow Management firm has again expanded its IT department to manage the increase in new business and service offerings. 

"We are pleased to announce the addition of Tobey Busch to our Information Technology Department. Tobey's title is Software Developer II, and will be working with us to enhance the functionality of our UCX system, among other projects. He brings a diverse level of experience that will complement our current staff", said Ryan O’Mahoney, VP of Operations at UCS. 

About UCS

United Claim Solutions is an innovative Medical Cost Reduction and Claims Flow Management company providing cutting edge and customizable programs for payers, employers, unions, reinsurers, accountable care organizations and health plans. UCS offers end to end services including Bill Review, Out-of-Network Bill Repricing, Bill Edits, Medicare Plus Repricing, PPO Administration, Medical Management, Clearinghouse Services, Data Warehousing, OCR/Scanning, and Plan Modeling. We provide solutions for Group Health, Workers’ Compensation, and Auto Liability. Contact UCS if you are looking for: 

• A partner that puts Service first
• Industry leading Savings on medical bills
• Flexible Solutions that reduce administrative costs

Contact Corte Iarossi, VP of Sales & Marketing at 866-762-4455 x 120, ciarossi@unitedclaim.com and visit www.unitedclaimsolutions.com.

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Market Trends, Studies, Books & Opinions


Few Self-Insured Plans Will Escape Paying Reinsurance Fees

MyHealthGuide Source: Todd Leeuwenburgh, 10/22/2014, Thompson Information Services Blog Entry

Only self-insured plans that completely self-administer claims payments and plan operations will avoid paying onerous transitional reinsurance fees. If a self-insured health plan does no more than determine eligibility, it will have to pay, according to Jeffrey Endick, an attorney with Slevin & Hart in Washington D.C.

An exception exists to the onerous fee $63 per-member-per-year fee:

  • Self-insured plans that virtually completely self-administer claims payments and plan operations are exempt from paying it.

But it appears few will qualify.

According to Endick, self-insured plans will lose the exemption if the plan uses a TPA for even one of four core claim-paying and adjudication functions. These include:

  • (1) repricing claims;
  • (2) sending out explanations of benefits;
  • (3) cutting checks for providers; and
  • (4) negotiating provider discounts.

Nov. 15 is the deadline for submitting information and scheduling payments for the fee. The payments are not due on Nov. 15, but employers must upload their information by that date.

In accord with that deadline, the Centers for Medicare and Medicaid Services published a 64-page manual to help insurers, third-party administrators and employers fill out their submissions. A separate set of instructions tells employers how to facilitate creation of the data to be submitted. CMS told the public that submission forms will be available on www.pay.gov for program enrollment and contributions data on Oct. 24.

The transitional fee must be paid by all health plans in order to help insurers pay for the high-cost individuals that they must cover because of health care reform's guaranteed-issue and no-rescission rules. All health insurers and third-party administrators on behalf of self-insured group health plans must pay into the fund.

"Reporting entities" will register on www.pay.gov on or before Nov 15, 2014 for the 2014 benefit year's annual enrollment, CMS said.

Employers may split the transitional reinsurance fee into two parts: they may submit an initial payment of $52.50 per covered life by Jan. 15, 2015 and a second payment of $10.50 per covered life by Nov. 15, 2015. They may also pay the entire $63.00 per covered life on or before Jan. 15, 2015.

The TR payment for 2015 becomes $44; and insurers and plans can make an initial payment of $33 in and subsequent payment of $11. The amount of the 2016 fee has not been made public yet.

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Legal, Legislative & Regulatory News


Payment Outside the Policy Period Does Not Necessarily Relieve Stop Loss Carrier From Liability

MyHealthGuide Source: Thomas A. Croft, Esq., The Self-Insurer, From the Bench, 10/22/14

This case addresses the novel issue of whether an insured group must continually pay claims in respect of a claimant during the policy period after a disclosure-based denial to preserve its rights.

Ohio Federal Court Holds Payment Outside the Policy Period Does Not Necessarily Relieve Stop Loss Carrier From Liability Where There Was a Previous Disclosure-Based Denial

Case: Florida Keys Electrical Cooperative Association v. Nationwide Life ins. Co., et al., No. 2:14-cv-372, S.D. Ohio, October 16, 2014.

This case decides an issue of first impression in the stop loss arena, and is significant for carriers, MGUs, TPAs and self-insured groups. Essentially, it holds that, once a carrier denies a claim on disclosure grounds, it is no longer necessary for the group to pay future claims for the claimant at issue in order to preserve its rights to sue the carrier for claims incurred but not paid during the coverage period set forth in the stop loss policy. This general statement is subject to various qualifications, as the discussion below shows.

Facts (as set forth in the Court’s opinion and as taken from the allegations of the Group’s Complaint)1:

The group, Florida Keys Electrical Cooperative Association ("Florida Co-op"), was insured under a Nationwide Life Insurance Company ("Nationwide") stop loss policy issued through its MGU, RMTS, LLC ("RMTS"). This was 24/12 policy, providing coverage above the specific deductible for claims incurred between January 1, 2009 -- December 31, 2010, and paid by the group between January 1, 2010--December 31, 2010.

The group’s Complaint alleged that it sought reimbursement for claims of $534,394.67, apparently incurred and paid by the group during the policy periods set forth in the stop loss policy, for claimant "TC," a dependent spouse, which were denied for disclosure reasons by RMTS on September 23, 2010 on behalf of Nationwide. Florida Co-op appealed the denial. The Court’s opinion is silent on what response RMTS made to the appeal, although Florida Co-op’s Complaint alleged neither RMTS nor Nationwide ever "formally" denied it, though they did not pay the claims.

In any event, Florida Co-op’s Complaint also alleged that additional amounts were incurred with respect to "TC" during the policy period, including a claim from a provider for more than $715,000, but that Florida-Co-op was able to negotiate a reduction of this amount to approximately $501,000.2

  • The problem: Florida Co-op did not actually pay the reduced hospital bill of $501,000 until sometime in 2012--well outside the policy benefit period.

Florida Co-op filed suit against Nationwide and RMTS in April 2014, alleging, among other things, that Nationwide breached its stop loss contract, not only as to the original $534,394.97 which it had paid during the policy period, but also as to the additional amounts that were not paid until 2012, after the policy period expired (hereinafter the "Late-Paid Claims"). Florida Co-op sought damages from Nationwide for breach of contract and under other theories. The claim against RMTS was based on alleged tortious interference with Florida-Co-op’s rights under the stop loss policy3.

The Motion and the Court’s Analysis

Both Nationwide and RMTS filed a motion for judgment on the pleadings as to the "Late-Paid Claims"--the claims paid in 2012. It is important to understand that this motion was not addressed to merits, vel non, of the disclosure issue itself, but was simply based on the fact that the approximately half a million dollars of the total of claims at issue were not paid within the policy window. In other words, Nationwide/RMTS wanted these amounts excluded from the lawsuit up front, based on the express terms of the stop loss policy, which required payment before December 31, 2010 for coverage to apply.

Florida-Co-op responded to Defendants’ motion by arguing that the previous denial of the claims relating to "TC" on disclosure grounds excused it from complying with the policy terms as to the "Late-Paid Claims." Indeed, Florida Co-op’s Complaint alleges that it did not even file a claim for reimbursement with Nationwide/RMTS for the "Late-Paid Claims," but nevertheless is entitled to reimbursement of them.

Anticipatory Breach of Contract

This brings us to the doctrine of anticipatory repudiation, or anticipatory breach of contract, which was determinative of the outcome of Nationwide/RMTS’s motion. Under Florida law as interpreted by the Court (there was likely a Florida choice of law provision in the stop loss policy),

  • "[a]n anticipatory breach of contract is one committed before the time when there is a present duty of performance, and is the outcome of words or acts evincing an intention to refuse performance in the future."

The Court observed that

  • "disavowing a contractual duty before the time specified in a contract for performing that duty has arrived is the very definition of an anticipatory breach."

The Court interpreted Florida Co-op’s Complaint to allege that the denial of the first claims for "TC" on disclosure grounds constituted an advance notice that all claims relating to "TC" in the future would be denied on these same grounds. As a practical matter, that seems sensible--once a stop loss claim has been denied on disclosure grounds, it is highly unlikely that future claims would be honored, as the disclosure issue that lead to the initial denial cannot be "cured" by subsequent action on the part of the insured.

The Court reviewed the options of a party to a contract upon an anticipatory repudiation by the opposite party, and concluded that one of them is for that party "to treat the repudiation as a breach…by making some change in position." Here, the Court concluded that Florid-Co-op’s decision to treat the denial of the first claims as a breach of Nationwide’s obligations to reimburse for all claims related to "TC" and its decision not to pay within the policy period and pursue negotiations with the provider was a legitimate response: "[Florida Co-op] did not have to engage in futile pursuit of reimbursement, including meeting its contractual obligation to pay under the policy. Rather, when an anticipatory breach occurs, the nondefaulting party is relieved of its obligations under the contract."

The Court went on to add an important qualification to Florida Co-op’s rights in this situation. Essentially, the Court held that Florida Co-op must be able to prove that it could have performed--that is, pay the Late-Paid Claims within the policy period--but simply elected not to do so in light of the anticipatory repudiation by Nationwide. While the Complaint did not expressly allege that Florida Co-op was ready, willing, and able to pay the Late-Paid Claims within the policy period, the Court concluded that such allegations could be inferred from the allegations of the Complaint, based on what the Court termed "judicial experience and common sense."

 Late-Paid Claims May be Reimbursable under the Stop Loss Contract

In summary, then, the Court decided that the fact that the Late-Paid Claims were not paid within the policy period was not alone fatal to Florida-Co-op’s rights to reimbursement under the stop loss contract. The Court stated:

  • "Whether this inference…that [Florida-Co-op] was ready, willing and able to pay remain[s] correct in light of the actual development of facts in this case remains just as open as the issue of whether Defendants indeed breached the contract [by denying the initial claims on disclosure grounds] does."

In short, Florida-Co-op was not tossed out on its ear just because the claims at issue were paid late. The propriety of the denial of all the claims on disclosure grounds remains an issue for trial, as does Florida Co-op’s ability to have paid the Late-Paid Claims within the policy period.

Author’s note: The "change of position" requirement appears to have been satisfied in this case by the group’s choice not to pay the Late-Paid Claims within the policy period and its pursuit of a discount with the provider instead. One wonders whether the result might have been different if Florida Co-op had simply waited until 2012 and not pursued negotiations with the provider. As a practical matter, a stop loss carrier’s denial of a claim on disclosure grounds should not automatically give an indefinite extension to a group to pay subsequent claims, or excuse even filing a stop loss claim for them.

The safest course in these kinds of situations for the group, obviously, is to pay all potentially eligible claims within the policy period, file timely claims for them in spite of the earlier disclosure-based denial, and eliminate the need for an "anticipatory breach" type argument. Note also that this case applied Florida law. The law on anticipatory repudiation can vary significantly from state to state.

About the Author

Thomas A Croft is a magna cum laude graduate of Duke University (1976) and an honors graduate of Duke University School of Law (1979), where he earned membership in the Order of the Coif, reserved for graduates in the top 10% of their class. He returned to Duke Law in 1980 as Lecturer and Assistant Dean (1980-1982) and as Senior Lecturer and Associate Dean for Administration (1982-1984). He also taught at the University of Arkansas-Little Rock law school, where he was an Associate Professor of Law (1990-91), earning teacher of the year honors.

Until 2004, when he specialized in medical stop loss litigation and consulting, Tom practiced general commercial litigation. He was a partner in the litigation section of a major Houston firm in the late 1980s, and moved to the Atlanta area in 1991. He has been honored as a Georgia "Super-Lawyer" by Atlanta Magazine for the last eight years running, and holds an AV® Preeminent rating from Martindale-Hubble®.

Tom currently consults extensively on medical stop loss claims and related issues, as well as with respect to HMO Excess Reinsurance, Medical Excess of Loss Reinsurance, and Provider Excess Loss Insurance. He maintains an extensive website analyzing more than one hundred cases and containing more than fifty articles published in the Self-Insurer Magazine over many years. See www.stoplosslaw.com. He regularly represents and negotiates on behalf of stop loss carriers, MGUs, Brokers, TPAs, and Employer Groups informally, as well as in litigated and arbitrated proceedings, and has mediated as an advocate in many stop-loss related mediations. Tom can be reached at tac@xsloss.com.

Footnotes

  1. Because of the procedural posture of the motion at issue, the Court was required to assume that the plausible allegations of the Complaint were true. See Fed.R.Civ.P.12(c); 12(b)(6); Bell Atlantic Corp. v. Twombly, 550 U.S. 554, 570 (2007).
  2. It is unclear from the Complaint or the Court’s opinion whether an additional $47,000 in claims relating to “TC” were paid during the policy’s benefit period or not.
  3. The author questions the viability of this theory under the general proposition that an agent, an MGU such as RMTS, cannot tortiously interfere with its principal’s contract under the law of many states. Typically, while not a party to the stop loss contract, the MGU is not a “stranger to the contract” legally capable of tortiously interfering with it. Florida law may or may not have different features.

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The Transitional Reinsurance Program -- Reinsurance Contributions

MyHealthGuide Source: CMS, The Center for Consumer Information & Insurance Oversight, CMS Article

The ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form will be available via www.pay.gov on Friday, October 24, 2014 in time for the 2014 benefit year's annual enrollment submission deadline of November 15, 2014. Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form Availability.

Overview

Section 1341 of the Affordable Care Act established a transitional reinsurance program to stabilize premiums in the individual market inside and outside of the Marketplaces. The transitional reinsurance program will collect contributions from contributing entities to fund reinsurance payments to issuers of non-grandfathered reinsurance-eligible individual market plans, the administrative costs of operating the reinsurance program, and the General Fund of the U.S. Treasury for the 2014, 2015 and 2016 benefit years.

Who Makes Contributions?

Health insurance issuers and certain self-insured group health plans offering major medical coverage that is part of a commercial book of business are contributing entities. For the purpose of reinsurance contributions, "major medical coverage" is defined in 45 CFR 153.20 as a catastrophic plan, an individual or a small group market plan subject to the actuarial value requirements under 45 CFR 156.140, or health coverage for a broad range of services and treatments provided in various settings that provides minimum value as defined in 45 CFR 156.145. A contributing entity must make reinsurance contributions on behalf of its enrollees in plans that provide "major medical coverage," as defined under 45 CFR 153.20, unless one of the exceptions provided under 45 CFR 153.400 applies to such coverage.

Although a contributing entity is responsible for the reinsurance contributions, it may elect to use a third party administrator or administrative services-only contractor for submission of enrollment data and the transfer of the reinsurance contributions.

How Does a Contributing Entity Make Reinsurance Contributions?

HHS is implementing a streamlined approach to complete the contributions process through Pay.gov. To successfully complete the reinsurance contribution process, contributing entities, or third party administrators or administrative services-only contractors on their behalf, must register on Pay.gov.

Using Pay.gov, the contributing entity (or third party administrators or administrative services-only contractors on their behalf) will access the "ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form" to enter the annual enrollment count. The ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form will auto-calculate the annual contribution amount to be remitted based on the annual enrollment count and the contributing entity will then schedule payment for the calculated reinsurance contributions on the payment page.

Key Reinsurance Contribution Deadlines for the 2014 Benefit Year

Date

Activity

Contribution Amount

October 24, 2014 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form Available on Pay.gov  
No later than
November 15, 2014
Contributing Entities Submit Annual Enrollment Count  
No later than
January 15, 2015
Contributing Entities Remit First Contribution Amount (or Combined Contribution Amount) $52.50 per covered life (if remitting first contribution amount)
or
$63.00 per covered life (if remitting combined contribution amount)
No later than
November 15, 2015
Contributing Entities Remit Second Contribution Amount $10.50 per covered life
(if remitting second contribution amount)
  Total $63.00 per covered life

We note that HHS will offer contributing entities the option to pay: (1) the entire 2014 benefit year contribution in one payment no later than January 15, 2015 reflecting $63.00 per covered life; or (2) in two separate payments for the 2014 benefit year, with the first remittance due by January 15, 2015 reflecting $52.50 per covered life, and the second remittance due by November 15, 2015 reflecting $10.50 per covered life.

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Medical News


PPOs Pay Higher Prices for Office Visits Where Competition Among Physician Practices is Less

MyHealthGuide Source: Laurence C. Baker, PhD, et al, Journal of American Medical Association, 10/22-29/2014, JAMA Abstract

Private preferred provider organizations pay higher prices for office visits in regions where there is less competition among US physician practices according to a study published in the Journal of American Medical Association.  Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services.

Researchers studied 1,058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.  Their goal was to assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.

Researchers measured the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10 000 in markets served by a single [monopoly] practice).

The mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (CPT code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.

Study Findings

  • Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.
  • Across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629).
  • Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75.
  • After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile.
  • Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher.

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Recurring Resources


Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 10/8/2014)

Source: MyHealthGuide

Editor's Note: The following is a recurring article. This Newsletter is often asked by readers for a list of medical stop-loss providers and their respective premiums. Below the first of a recurring article that attempts to lists stop-loss providers and annual premiums. Sources includes press releases, AM Best reports, conference presentations and more.

Stop-loss Premium Ranking
Compiled by MyHealthGuide Newsletter

Reader response and correction is encouraged.
Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
(Millions)
Capital /Equity
(Millions)
Source
1. CIGNA     $1,907
2013
  CIGNA 2013 10-K, page 46 2/27/2014
2. Sun Life Financial     $915.2
2013
  Scott Beliveau, Sun Financial 4/28/2014
3. HCC Life Insurance Company >35 Years HCC Life
(A.M. Best Rated: A+)
Perico Life
(A.M. Best Rated: A+)
$818
2013
  HCC Insurance Holdings, Inc. Release,
2/11/2014
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
$762.4
2013
$507
12/31/2013
Mike Sullivan, President & COO
2/4/2014
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $475M
MRM - $255M)
$730
2012
$3,429
6/30/2014
Michael Fry, Executive Vice President, Symetra;
Mike McLean, Chairman Medical Risk Managers, Inc.
1/7/2014
6. ING Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
$560
2013
$1,942
12/31/2013
Joe Keller, Lead Financial Analyst, ING Employee Benefits,
3/18/2014
7. Companion Life > 20 Years   $440
10/8/2014
  Philip Gardham, Vice President, Specialty Markets,
10/8/2014
8. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
5/2014
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
6/20/2014
9. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
$200   Roy T.K. Thung, CEO, Letter to Stockholders
3/31/2014
10. Zurich North America     $130   Tracey Brennan, Zurich North America.
7/22/2011
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
2012
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
4/25/2013
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
$96
2/2014
  Victor Moran, Second Vice President, Actuarial Operations.  3/12/2014
13.
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $$3,388
12/31/2011
Mark Nichols, Managing Director.
7/20/2012

Other stop-loss leaders include the following list. However, we await reader response providing stop-loss premium volume (and additional carriers) so that each could be added to the table above. 

  • ACE America
  • Aetna
  • Amalgamated Life
  • American Fidelity Assurance Company 
  • American National Life Insurance Company of Texas
  • Berkley Accident and Health
  • BEST Re 
  • Blue CrossBlue Cross Blue Shield (various regions)
  • Gerber Life Insurance Company
  • International Insurance Agency Services, LLC
    (IIS)
  • Lloyd's of London
  • Nationwide Life Insurance Company
  • Pan American Life
  • QBE Insurance Company
  • Trustmark Insurance Company
  • UnitedHealthcare

Stop-loss Premium Volume is not the Whole Story

Industry executives question the purpose of a chart reporting only stop-loss premium without additional information such as:

  • Ratings from Best, S&P, Moodys and others (data collection began 6/2012)
  • Capital size of the insurance company (data collection began 6/2012)
  • Reinsurance purchased and from whom
  • Length in the business (data collection began 6/2012)
  • Number of open litigation claims
  • Is stop-loss a core business or ancillary business?
  • % age of risk retained vs. ceded
  • Average stop-loss claim processing turn-around time
  • % age of claims denied
Should reader interest indicate such measures are important, this Newsletter will attempt to collect and report.  

Reader response and correction is encouraged. Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com.  

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Upcoming


October 30, 2014 - Webinar 1 PM Eastern
Creeping Around Pitfalls on the Way to Scary Savings? - How to Avoid Horror When Implementing Cost Containment Schemes presented by The Phia Group CEO, Adam Russo, Sr. VP & General Counsel, Ron Peck, and other members of the legal team.  Many are questioning how far they can go with dialysis carve-outs, without running afoul of the Medicare Secondary Payer Act. Are the tricks piling up, but no treats are in sight? The HHS has announced a scheme to crush skinny plans. If that isn't enough to scare you straight, someone had better check for a heartbeat!  Don't be left "holding the bag." Whether you're embarking on a new cost containment adventure in-house, or with the help of a vendor, most programs are not simple "plug and play" affairs. Those who head into the dark unprepared will undoubtedly find themselves spooked by what hides around the corner. Information and registration.

November 5, 2014
Clearwater Information Risk Management Virtual BootCamp™. Offering the convenience of online learning, this virtual course is geared toward leaders, information security and risk management professionals who are responsible for ensuring their organizations understand and manage their information security risks appropriately. Our robust curriculum is designed to equip participants to conduct a bona fide HIPAA Security Risk Analysis based on the NIST framework and -- just as importantly -- implement a strong, ongoing Risk Management program. Contact Clearwater Compliance 800-704-3394 and info@clearwatercompliance.com.

November 5, 2014 - Webinar at 2:00 pm Eastern
Election 2014: The Midterm Results, the ACA and You presented by Sun Life Financial.  James Slotnick, Sun Life Financial, AVP, Broker Education & Advanced Markets will break down the results of the prior day's mid-term elections with an in-depth analysis of if -- and how --the changing landscape will affect the future of health care and the Affordable Care Act.  For over a decade, James Slotnick has helped employee benefit brokers, financial advisors, and the end-consumer understand the ever-changing insurance industry. Leveraging his sales and legal backgrounds, James is able to break down complex insurance topics into understandable concepts that help both brokers, HR decision-makers, and end-consumers make informed decisions. Registration and information

November 10-12, 2014
4th Annual IHC FORUM West presented by Institute for HealthCare Consumerism.  Join employers, brokers, health plans, TPA's, consultants and solution providers to LEARN, CONNECT and SHARE HealthCare Consumerism trends, challenges and solutions including:
Learn next steps and best practices in HealthCare Consumerism, Compliance issues with health care law in 2015 and beyond, Access latest health and benefit innovations and trends, Look into real time open enrollment statistics, Perspectives on election results, Analyze benefit models, including defined contribution and exchanges, Network with your peers and other industry stakeholders, Receive top quality education, more.  Red Rock Resort & Spa. Las Vegas, NV. Free registration for first 25 to register by September 15, 2014 using the registration code is MYHEALTHGUIDEVIP. Information and registration: www.theihccforum.com/2014west/

November 17-19, 2014
The Ops/Tech Forum, hosted by America's Health Insurance Plans, gathers industry experts to discuss critical issues such as: consumer engagement, exchange implementation, cost drivers, data analytics, and innovative technologies. Gain insights on the strategies, tools, and solutions you need to guide you into 2015 and beyond. Register today! Contact: 202-778-3200 or registrations@ahip.org

December 1-3, 2014
HCISPP Training -- Nashville presented by Clearwater Compliance.  This official HCISPP training seminar is the most comprehensive, complete review of healthcare security and privacy concepts and industry best practices. The training specifically covers each element of the HCISPP common body of knowledge (CBK®), including foundational information on:

• The Healthcare Industry
• The Regulatory Environment
• Privacy and Security in Healthcare
• Information Governance and Risk Management
• Information Risk Assessment
• Third Party Risk Management

Cost of the Clearwater HCISPP training is $1,595. Registration dates:

• February 9-10-11, 2015 -- Miami, FL
• April 6-7-8, 2015 -- Nashville, TN
• June 1-2-3, 2015 -- Nashville, TN
• August 10-11-12, 2015 -- Nashville, TN
• October 5-6-7, 2015 -- Miami, FL
• December 2-3-4, 2015 -- Nashville, TN

Contact Helen Cuddeback at 615-913-4510, helene.cuddeback@clearwatercompliance.com and visit www.clearwatercompliance.com

December 4-5, 2014
IHC Forum West presented by the Institute for HealthCare Consumerism. Las Vegas, NV. Contact Joni Lipson at jlipson@theihcc.com and visit www.www.theihccforum.com/2014-ihc-forum-and-expo/

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January 18-20, 2015
The 2015 Taft-Hartley Benefits Summit presented by Financial Research Associates, LLC.
Caesars Palace in Las Vegas. Contact Jennifer Clemence at jjclemence@frallc.com.  Information and registration: www.frallc.com/register.aspx?ccode=B940 and visit
www.frallc.com

January 25-27, 2015
AAPAN 2015 Annual Forum presented by American Association of Payers Administration & Networks.  The theme for this year's forum is "Thinking Forward -- Rethink, Retool, Realign." This will be your opportunity to join industry leaders and an exciting lineup of speakers as we examine how best to position our businesses in this fundamentally changed healthcare environment. You will hear firsthand from experts and colleagues about challenges and opportunities at the state and federal level that are unique to TPAs, PPOs, and Workers' Comp professionals. Information: aseiler@aapan.org and (502) 403-1122.  Ritz-Carlton, Laguna Niguel in Dana Point, CA.

February 10-11, 2015
2015 Executive Forum presented by Heath Care Administrators Association (HCAA).  Encore at Wynn Las Vegas. Las Vegas, NV. www.HCAA.org.

March 4-6, 2015
Self-Insured Health Plan Executive Forum presented by Self-Insurance Institute of America.  J.W. Marriott Camelback, Scottsdale, AZ.  www.SIIA.org

March 18-20, 2015
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org


April 13-15, 2015
International Conference presented by Self-Insurance Institute of AmericaHilton Panama, Panama City, Panama. www.SIIA.org

April 29-30, 2015
Self-Insured Taft-Hartley Plan Executive Forum (NEW EVENT!) presented by Self-Insurance Institute of America. Marriott Metro Center, Washington, DC www.SIIA.org

May 6-8, 2015
Northshore's 26th Annual Claims Conference.  Salem, Massachusetts. This is an invitation only event. If you are interested in attending or presenting at next year's conference, you may contact Steve Murphy at smurphy@niis.com


May 12-14, 2015
Self-Insured Workers' Compensation Executive Forum presented by Self-Insurance Institute of America. Windsor Court Hotel, New Orleans, LA www.SIIA.org

July 21-23, 2015
MCIA Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA) at the Lodge at Whitefish Lake in Whitefish, MT.  Contact mcia@mtcaptives.org and visit www.mtcaptives.org

October 18-20, 2015
National Educational Conference & Expo presented by Self-Insurance Institute of America. Marriott Marquis, Washington, DC  www.SIIA.org

September 28-30, 2015
SPBA Fall Meeting (members only). Scottsdale, AZ. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

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March 30-April 1, 2016
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

October 17-19, 2016
SPBA Fall Meeting (members only). Minneapolis, MN. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

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March 15-17, 2017
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

September 13-15, 2017
SPBA Fall Meeting (members only). Cincinnati, OH. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

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Editorial Notes, Disclaimers & Disclosures


  • Articles are edited for length and clarity.
  • Articles are selected based on relevance and diversity.
  • No content in this Newsletter should be construed as legal advice. All legal questions should be directed to your own personal or corporate legal resource.
  • Internet links are tested at the time of publication.  However, links change or expire often.
  • Articles do not necessarily reflect views held by the Publisher.
  • Disclosure: Owner of MyHealthGuide also has ownership interest in CareHere, LLC® and LabInsight®
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Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
Clevenger@MyHealthGuide.com