SIIA's Successful Singapore Conference Explored Global Self-Insurance/ART Solutions

MyHealthGuide Source: The Self-Insurance Institute of America, Inc. (SIIA) , 2/3/2010, www.SIIA.org

The Self-Insurance Institute of America, Inc. (SIIA) continued its exploration of alternative risk funding and transfer solutions on a global basis last week in Singapore, during its Second Annual International Conference.

The event emphasized transformations in the healthcare and employee benefit industry, addressing key topics such as administration, strategic alliances and financing mechanisms. Other self-insurance solutions, including captive insurance, were discussed by the international audience coming from China, Belgium, Germany, Malaysia, Thailand, India, U.A.E., and of course the United States and Singapore.

A spectacular venue was provided for attendees from some of the world's leading companies within the self-insurance/ART marketplace to dialogue and share their thoughts on opportunities and challenges within the international community.

The conference opened with a concentration on the evolution of the healthcare industry within specific countries and regions. It also focused on the market's need to continually evolve in order to keep up with changing healthcare and employee benefit needs.

The first speaker of the morning, Michael Feighan, Vice President of Worldwide Underwriting, Chubb Accident & Health, provided a comprehensive report contrasting several different supplemental accident and health insurance products from around the world. He outlined opportunities and challenges and identified where self-funding/alternative risk transfer might be accepted as an option within the country's current regulatory structure and would respond to growing middle class population and need for improved employee benefit packages to attract the best employees.

The second session focused on how countries around the world struggle to find solutions to their healthcare exposures and the many companies that are developing creative products that address these risks on a global basis. Roberto Leonardi, Head of Regional Markets, Asia Pacific, of Munich Re, explained how they are collaborating with the private and public sectors to bring innovative solutions to the service providers in targeted international regions.

Dr. Daniel Chan, deputy CEO of East Shore Hospital and Raymond Chong, CEO of Samitivej Health, led an afternoon session by giving their perspectives on the attraction of Global Health in Singapore and Thailand. They also discussed the options that private hospitals are providing to citizens from around the world which have driven the demand for new innovations, business partnerships and state-of-the-art facilities.

The second day of the conference began with a presentation from Greg Arms, Global Head - Employee Benefits Practice, Marsh. He discussed the benefits of multi-national pooling, captive structures and the utilization of these for international employee benefit arrangements.

Armando Baez, President, Global Benefits Group Shanghai, then presented on his experience setting up a TPA in China, the regulatory requirements, and how to mitigate some of the challenges presented when opening a business in another country.

This case study was followed by several sessions that concentrated on mitigating global medical risks, developing provider networks, emerging markets, new global healthcare service opportunities for captive insurance programs and actuarial considerations.

Prior to the conference, several SIIA delegates traveled to Thailand to learn more about "medical travel", the transformation of the healthcare industry and what products and business ventures may lie ahead. The delegates visited two private hospital facilities that provide services to expats, private policy holders, and patients from other countries seeking quality care at a reasonable cost.

The second day of the tour, Lucien Heijstee, Executive Vice President of Thaivivat Insurance and Eduard Siauw from CIGNA Thailand educated SIIA delegates on insurance schemes, the regulatory environment, challenges in the insurance industry as well as opportunities in Thailand.

In all, the SIIA conference effectively enlightened its attendees on global healthcare and employee benefit industry trends and the need/opportunity for alternative risk financing and partnering mechanisms.

During this conference old relationships were reignited, new relationships were forged, old ideas were reshaped and new ideas were born!

SIIA's Singapore Sponsors

SIIA would like to extend a special thank you to Veiovis, Ebix Health, Global Medical Conexions, Global Benefits Group, and Public Healthcare Group, Singapore for supporting SIIA's international division and sponsoring the 2nd Annual International Conference.

The next stop for SIIA's international outreach will be London, where the association will be holding a conference June 7-9, 2010. Details about this event can be accessed on-line at www.siia.org/London.

SIIA will also feature an international track of educational sessions as part of its National Conference & Expo, scheduled for October 12-15, 2010 in Chicago.

About SIIA

The Self-Insurance Institute of America, Inc. (SIIA) is a dynamic, member-based association dedicated to protecting and promoting the business interests of companies involved in the self-insurance/alternative risk transfer (ART) industry, both domestically and internationally.  Visit www.SIIA.org.

Top

Click4Care Partners with iWay to Speed Care Management Technology Adoption

MyHealthGuide Source: Click4Care, 2/2/2010, www.Click4Care.com and www.iwaysoftware.com

Powell, OH -- Click4Care, a leading provider of care management software for payors, announced that it has forged a partnership with iWay Software, a provider of service oriented architecture-based (SOA) enterprise integration tools, to help Click4Care clients quickly and cost-effectively integrate disparate information technology (IT) systems with its award-winning care management platform. iWay's streamlined, scaleable and robust integration model enables healthcare payors to rapidly interface Click4Care's software with their claims processing system, member and provider databases, decision support, document management and other best-of-breed IT applications.

"With a rapidly aging population and nearly half of all adult Americans living with a chronic condition, the payor community will face even greater pressure to promote and provide higher quality and cost-effective care management," said Gerald Cohen, CEO and president of iWay. "To successfully achieve this goal, payors must integrate data and workflows that currently reside in separate IT systems, enabling them to collaborate and share information more efficiently with care managers, members and providers."

Cohen continues, "By combining iWay's powerful solutions and SOA integration approach with Click4Care's innovative care management platform, payors will mitigate technology implementation risks and enhance their ability to keep members healthier, identify at-risk members more quickly and thoroughly, improve physician satisfaction and collaboration, and gain greater control over their financial and operational outcomes."

"In working with payors of all sizes, we noticed a trend toward adopting sophisticated, member-centric care management approaches that leverage the interoperability and data integration of multiple IT systems," said Rob Gillette, Click4Care's CEO. "Click4Care's strategic relationship with iWay helps our clients more readily design and deploy these technology-driven programs to ultimately enhance the quality of member care, improve member satisfaction, advance care coordination and reduce clinical and administrative costs."

Click4Care's award-winning care management software suite allows payors to aggregate critical patient information to identify the members who would benefit most from active care management. The software's robust functionality offers health plans, health insurers and third party administrators the only fully integrated view of all member activity across utilization management, disease management, case management, and health and wellness management. Supported by an agile architecture, the platform's unrivaled configurability can quickly and easily accommodate each payor's unique workflows, policies and business processes.

About iWay Software

iWay Software's integration methodology is simple: it uses a single, integrated set of graphical design tools to assemble powerful pre-built components for enterprise-class business-to-business (B2B) integration, business process automation (BPA), or enterprise information management (EIM) integration scenarios - without the use of custom code. Integration configurations can be deployed in a stand-alone manner to any environment supporting a JVM - or to Web application servers from any vendor. iWay delivers the fastest, most cost-effective, and simplest way to integrate and streamline critical business processes. iWay Software's vendor-, platform-, and protocol-neutral solutions achieve the promise of SOA: true reusability. Visit www.iwaysoftware.com.

About Click4Care

Click4Care™ provides innovative care management software, integrating data from multiple systems into a solution that automates and optimizes patient care. Streamlined workflows and improved operational efficiencies drive unprecedented return-on-investment for care managers, while providing life-improving care to patients. Click4Care is driving enterprise-wide changes in the processes and business models of healthcare delivery. Some of the world's most progressive health insurance providers rely on Click4Carefor a more member-centric approach to care management. Visit www.Click4Care.com.

Top

CDHC Solutions Announces Opportunity to Showcase CDHC Products and Services to TPAs Brokers, Banks, Benefits Consultants, and Health Plans on May 18th in Atlanta

MyHealthGuide Source: FieldMedia LLC, publisher of CDHC Solutions, 2/4/2010, www.cdhcsolutionsmag.com

Why a Single-Day Event Focused on Consumer-Directed Health Care?

1. Consumer-Directed Health Plans (CDHP) are proving themselves in the market and more companies are strongly considering full conversion programs. Also Health Savings Accounts currently appear to be in good shape with health care reform legislation if a version ever passes. Many employers need help in improving their current programs or learning the how-to's of implementing them for the first time.
    
2. No conference focuses exclusively on the A-to-Z of consumer-directed health care—this subject is touched on by benefits, HR and health care conferences, but not in-depth. Also many beltway conferences are focusing on policy, but not on best practices and emerging solutions.
    
3. Employers, TPAs, brokers, banks and benefit consultants have a real need for this information but have little-to-no budget or time to travel to a multi-day event. We will bring the events to them in a focused, educational format with plenty of opportunities for networking in a peer-to-peer environment.
    
4. Sponsors waste a lot of money at HR, benefits and health care conferences or inside beltway events not connecting with the right audience—competing for too few attendees, enduring cluttered visibility as a sponsor/exhibitor and dealing with low turnout at workshop sessions. The CDHC Solutions Forum will provide sponsors with high visibility and connection sponsors need with the right attendees.
    
5. The CDHC Solutions Forum events will be located in regions that are not being served by national conferences, such as Atlanta for the first event (May 2010).
    
6. The Forums are a natural extension of CDHC Solutions' editorial focus and readership of 46,000 employers, TPAs, benefits brokers, banks, consultants and regional health plans.
    
7. With the combination of CDHC Solutions and sister magazine and web community --   www.EmployersWeb.com -- we will be reaching out to create awareness and promote this event to over 70,000.

Conference Program Agenda

The goal is to showcase employer, TPA, broker and solution providers who can share thought leadership in their areas of expertise and best practices.

• 7:30 a.m. - 9:00 a.m. Registration/Continental Breakfast and networking with sponsors
• 9:00 a.m. - 9:15 a.m. Welcome and Opening -- Doug Field, CEO, FieldMedia LLC
• 9:15 a.m. - 10:15 a.m. Opening General Session: Outlook for Consumer-Directed Health Care (including best practice showcase)
• 10:15 a.m. - 10:45 a.m. Beverage Break with Sponsors
• 10:45 a.m. - 11:45 a.m. Breakout Session (attend one of four)
  • Supplemental Health: Providing the Right Mix for Your Employees
  • Improving Employee/Consumer Engagement
  • Onsite Health Services and Convenient Care Clinics: What Works and for Whom?
  • Utilizing Rewards and Incentives to Influence Decisions on Improved Health
• 11:45 a.m. - 1:15 p.m. Lunch with Speaker: Healthcare 2010 -- The Role of the  Consumer
• 1:30 p.m. - 2:30 p.m. Breakout Session (attend one of four)
  • Creating a Culture of Health in the Workplace
  • Emerging Consumer Education Tools
  • Financial Trends impacting Health Savings Accounts
  • Supplemental Health: Dental and Vision
• 2:45 p.m. - 3:45 p.m. Breakout Session (attend one of four)
  • Pharmacy Benefit Management and Consumer-Directed Healthcare
  • Medical Tourism Benefits: Where Do They Fit?
  • Technology Solutions for CDH and Ways to Control Cost
  • Communicating and Educating the Benefits of CDHP to Your Employees
• 3:45 p.m. - 4:15 p.m. Beverage Break with Sponsors
• 4:15 p.m. - 5:15 p.m. Closing General Session: Employer Roundtable Discussion

Attendee Pricing

• Employers (Private Sector) $395 ($295 early bird before 3/20/2010)
• Employers (Public Sector) $325 ($225 early bird before 3/20/2010)
• TPAs, Benefit Brokers, and Consultants $595 ($495 early bird before 3/20/2010)
• Solutions Providers $995 ($895 early bird before 3/20/2010)

Sponsorship Pricing

Special Early Bird pricing for sponsorships: Signed sponsorship agreement with 50% down payment by January 29, 2010. Remaining balance due March 20, 2010.

• GOLD SPONSOR (3) LEVEL  -- $15,000
• SILVER SPONSOR (12) LEVEL -- $10,000
• BRONZE SPONSOR (5) LEVEL -- $8,000

About FieldMedia, LLC

FieldMedia, LLC. is the publisher of CDHC Solutions magazine and www.EmployersWeb.com the magazine, the industry's only business magazines and companion web sites focused on health care benefit solutions, health care benefit plan design, communications and education, total rewards and recognition and solutions to help companies better manage the health and wellness of their employees and/or member populations.  Contact Doug Field, CEO, FieldMedia LLC. at 404-783-9820 or dfield@fieldmedia.com or Drew Collins at 404-784-8994, dcollins@fieldmedia.com and visit www.cdhcsolutionsmag.com

Top

MyHealthGuide Source: Arbitration Forums, Inc. (AF), 2/1/2010, www.arbfile.org

TAMPA, FL -- Arbitration Forums, Inc. (AF), the nation's largest provider of inter-insurance dispute resolution services, resolved more than 520,000 inter-company claims disputes valued at nearly $2.5 billion in 2009, a new record, said W. Russ Smith, president and chief executive officer of AF, which has some 4,300 carrier and self-insured members nationwide. 

Smith noted that AF is saving the property/casualty insurance industry more than $700 million in litigation costs annually through programs that effectively resolve insurance claims disputes. In 2008, AF resolved some 500,000 inter-company claims disputes valued at more than $2.4 billion.

Disputes leading to arbitration typically arise when self-insured or insurance companies believe their insureds are not at fault or due to disagreements over the percentage of liability or the amount of damages, Smith explained. Over 85% of inter-company arbitration disputes involve auto collisions.

He pointed out that over 92% of the arbitration filings in 2009 were made electronically-almost double the percentage of just a few years earlier.

"AF continues to invest in ways the industry can effectively and efficiently resolve subrogation claims," said Smith. "As a not-for-profit, we are committed to serving the industry's needs, and an electronic, end-to-end subrogation and resolution claim process is another way we can do so."

16.2 days is Average Time from Filing Subrogation Claim to Closing Using E-Subro Hub

Smith noted that AF continues to expand E-Subro Hub, an electronic subrogation claims system offered to participants at no cost that is designed to dramatically increase productivity and efficiency of the subrogation process.

AF projects that phase one of the E-Subro Hub system rollout will save property/casualty insurance companies and self-insureds hundreds of millions of dollars annually by enabling users to electronically send and receive subrogation claims, attach supporting documents, manage subrogation claims and electronically file intercompany arbitration where necessary. AF's first paperless arbitration hearing was conducted last year, setting the foundation to easily move disputed claims from E-Subro Hub to arbitration.

The ease of use and reliability of E-Subro Hub, demonstrated by extensive pilot testing in Massachusetts and Mid-Atlantic states, convinced a group of the industry's leading company claims executives to adopt the system beginning with California and Pennsylvania.

The average time from filing a subrogation claim to closing was 16.2 days using E-Subro Hub in the pilot test states, reducing turnaround times by more than 50% in many instances.

The pilot tests also found improvements in customer service, as subrogation demands were accepted in just 10.4 days on average, allowing insurers to return deductibles to their policyholders faster.

Smith added that AF announced changes to its fee structure and clarifications to the Forum Rules that-in conjunction with 2009's notification service fee elimination-will save the industry $4 million annually and further speed the arbitration process.

About Arbitration Forums, Inc. (AF)

Founded by the insurance industry in 1943, AF is a membership-driven, not-for-profit organization that exists to effectively and efficiently serve its over 4,300 members' recovery and resolution needs. AF is the nation's largest arbitration and subrogation services provider, through which its members file more than 520,000 disputes worth nearly $2.5 billion in claims each year.  Visit www.arbfile.org.

Top

HealthEdge's 2009 Successes: Implementations, Support of ICD-10, Benefit Predictor Availability and More

MyHealthGuide Source: HealthEdge, 2/3/2010, www.healthedge.com

BURLINGTON, Mass -- HealthEdge, provider of the only modern enterprise-class software platform for healthcare payors, announced a landmark 2009 with significantly increased revenues and a series of achievements that have distinguished the company as an industry leader and innovator.

"Payors are facing a perfect storm of converging forces that threaten their ability to survive in the rapidly evolving healthcare market unless they can fundamentally change how they do business," explained HealthEdge CEO Rob Gillette. "Most health insurers are saddled with decades-old, legacy-based technology infrastructures that aren't up to the task. Our record growth reflects the surging recognition by health insurers and industry analysts that HealthEdge's one-of-a-kind, language-based technology platform, continuous innovation, winning team, and timely new products provide a previously unachievable level of real-time configurability and efficiency that payors are demanding."

Looming healthcare reform and regulatory changes, the mandated conversion to ICD-10, and growing calls for financial accountability, transparency, responsive customer service and true consumer choice propelled HealthEdge to center stage in 2009. Notable achievements included:

Increased Market Demand

Over the past eighteen months, HealthEdge has signed and implemented a number of new clients, including BenefitMD (Tacoma, Wash.), Mississippi Administrative Services (Brandon, Miss.), Neighborhood Health Plan of Rhode Island (Providence, R.I.), and SeeChange Health (San Francisco). All of these organizations are recognized leaders and innovators.

Award-winning Technology

HealthRules was voted "Best New Technology" in the insurer category at the 2009 Healthcare IT Summit, an event that brought together Gartner analysts, executives from many prominent healthcare organizations, and a number of leading technology vendors for collaborative discussions related to pressing business and IT issues, best practices, and the latest tools and technology. The winner of the award was selected based on votes from hundreds of senior business and technology executives who attended the Summit. This second Healthcare IT Innovation Award further validates HealthEdge's ability to develop uniquely powerful, market-changing technology and capabilities that enable payors to easily and cost-effectively transition to the member-centric world of 21st century healthcare.

Seamless ICD-10 Conversion

In 2009, the HealthRules Payor technology platform became the first to fully support ICD-10, including the ability to simultaneously use both ICD-9 and ICD-10 codes. This ensures a problem-free transition on the customer's timetable, without the need for any configuration changes or downtime.

Enhanced Customer Service with Benefit Predictor

The addition of Benefit Predictor to the HealthRules platform transforms the customer service experience for members. With a few keystrokes, a customer service representative can instantly and accurately answer the most complex questions about an individual's coverage, out-of-pocket expenses, history, wellness incentives, care management programs, and more - all specific to that member.

Strategic Partnerships Expand Value

As part of its ongoing efforts to enhance the value it provides to its customers, HealthEdge formed strategic alliances with several key partners in 2009, including:

• iWay Software, a leading provider of enterprise integration tools, which enables HealthEdge's clients to quickly and cost-effectively integrate their internal systems, partner networks and exchanges with HealthRules, significantly reducing deployment time and costs
   
• maxIT Healthcare, a leading healthcare consulting firm, which provides a full range of implementation and integration services for HealthEdge clients, including system installation, configuration, training, data conversion, maintenance and project management
   
• Bloodhound Technologies, whose ConVergence Point service offers HealthEdge clients improved claim efficiency, faster issue resolution, greater overpayment savings and superior fraud detection

"We are extremely pleased with our 2009 results, and view this outstanding year as a launching pad for even more impressive accomplishments in 2010 and beyond," said Ray Desrochers, HealthEdge's COO. "We are confident that our robust sales pipeline and upcoming product announcements will fuel our continued success as forward-thinking payor organizations turn to HealthEdge to achieve an unprecedented level of business agility and operational efficiency."

About HealthEdge

HealthEdge® provides the only modern, enterprise-class software platform for healthcare payors. Using the patented HealthRules® software suite, health plans and other payors can respond to business opportunities and market changes within hours rather than the usual months or years, while drastically reducing both IT and operational costs. Leveraging an investment of over $125 million, HealthRules is the most modern, scalable and cost-effective technology in the industry. HealthEdge provides the competitive advantage that enables payors to thrive in the dynamic healthcare environment. Visit www.healthedge.com.

Top

BCI Adds Craig Rowe a Marketing Consultant

MyHealthGuide Source: Benefit Communications Inc. (BCI), 2/3/2010, www.benefitcommunications.com

Nashville, TN -- Benefit Communications Inc. (BCI) announced the addition of Craig K. Rowe. Rowe is based in Nashville and will be covering markets throughout the US as a marketing consultant. Rowe has been involved in the HR and benefits arena on an international basis for the past 16 years.

Pride Scanlan, BCI Principal, said, "Our growing team is unsurpassed in experience and industry knowledge. Our ability to attract key players such as Rowe combined with quality acquisitions continues to reinforce our position as a national leader."

Rowe said "I am extremely excited to be joining the BCI team. For the last 30 years they have been at the forefront of their industry continue to invest in technology and people. In addition, their retention of clients has been unparalleled due to their focus on service quality and value. I look forward to the fast pace this opportunity presents."

"Craig's knowledge brings a proven track record that combines 16 years consulting experience with employers in our market. We are pleased to welcome him to our team and look forward to his insight as we create services that our clients require," stated Jim Hunt Jr., BCI Principal.

About BCI

Benefit Communications Inc. (BCI) has designed and delivered employee benefit programs in conjunction with services related to data management, education, enrollment, and communication for over 30 years. BCI partners with TPAs, insurance brokers, consultants, and insurance companies. Their clients include a wide diversity of industries including healthcare, transportation, retail, financial services, and manufacturing. In addition to Nashville, BCI also has offices in Chicago, Charlotte, Birmingham, Phoenix, and Tulsa.  Contact Pride Scanlan at (615) 292-3786 ext. 625, pscanlan@benefitcommunications.com and visit  www.benefitcommunications.com.

Top

MyHealthGuide Source: CIGNA Corporation (NYSE: CI), 2/5/2010, www.CIGNA.com

BLOOMFIELD, CT -- CIGNA Corporation announced that physician executive Alan Muney, M.D., MHA, will join the company as senior vice president, total health and network, to lead the company's health management and network contracting activities.

"We believe passionately in working to keep people healthy, providing support when illness or disability strikes and in taking a holistic approach to improving health. Alan is a respected physician executive who demonstrates this same passion"

In this role, Dr. Muney will lead the company's integrated team of doctors, dentists, nurses, behavioral health clinicians and other health professionals who deliver health management and wellness programs to CIGNA customers. He will also be responsible for CIGNA's relationships with the physicians, hospitals and other health care facilities, behavioral health experts, dentists and dental specialists who participate in CIGNA's networks around the country. Muney will be based in Bloomfield, CT, the headquarters for CIGNA's U.S. health care operations.

"We believe passionately in working to keep people healthy, providing support when illness or disability strikes and in taking a holistic approach to improving health. Alan is a respected physician executive who demonstrates this same passion," said Matt Manders, president, U.S. service, clinical, and specialty for CIGNA. "He understands the promise we make as a company and has joined our team to help us drive that value to the people we serve and to the health care professionals who deliver care to our customers each and every day. Alan has extensive experience in managing health care operations and in partnering with the clinical community to encourage and deliver accessible, quality and affordable health care."

Muney joins CIGNA from The Blackstone Group, a leading private equity group, where he served as executive director in the portfolio operations group. He was also chief executive officer of Equity Healthcare, which he founded to improve health outcomes and lower medical costs for employees of portfolio companies. He has more than 25 years experience leading health plan operations and in medical group practice management, having served during his career as chief medical officer for Oxford Health Plans and NYLCare, both in the New York-metro region; and as regional medical director and director of pediatrics of Mullikin Medical Centers in California.

Board-certified in pediatrics, Muney is a graduate of Brown University, where he received both his bachelor's and medical degrees. He completed his internship, residency and fellowship in pediatrics at Washington University Medical Center in St. Louis and received his master's of healthcare administration degree from the University of La Verne in La Verne, Calif. He is licensed to practice in the states of Connecticut, New York and California.

Muney has served on the Brown Medical School Alumni Board of Directors and on the Board of Directors of the Fairfield County chapter of American Heart Association. He has also served on the editorial advisory boards of the American Journal of Managed Care and Health Plan Magazine and on the scientific advisory board of the Institute for the Study of Aging.

About CIGNA

CIGNA (NYSE:CI), a global health service company, is dedicated to helping people improve their health, well-being and sense of security. CIGNA Corporation's operating subsidiaries provide an integrated suite of medical, dental, behavioral health, pharmacy and vision care benefits, as well as group life, accident and disability insurance, to approximately 46 million people throughout the United States and around the world.  To sign up for email alerts or an RSS feed of company news, log on to http://newsroom.cigna.com/rss/. Also, follow us on Twitter: @cignatweets.  Visit www.CIGNA.com.

Top

Health reform thinking on Capitol Hill and in the White House these days has been described as "the trolley to make-believe". Another calls it "full bluff mode". It is as if the players are in different realms of reality from day to day. Some is the normal posturing and puff talk for the media and audiences. Some of it is desperation, and some of it is like a caged animal probing every possible way to break free.

First, remember that it isn't over until it is over (end of 2010, when this session of Congress ends). For example, some Democratic and White House leaders are trying to hatch a desperate (but clever) gambit based on a "ping-pong" strategy.

Senate Bill Sent to the President to Sign Into Law

The clever plan would be to have the players decide on a strategy by Presidents' Day Congressional vacation:

• When members come back, they pass a jobs bill as a feel-good and diversion for voters and the media.
• House passes a Reconciliation bill that looks fairly innocent with simply the changes that the House members would demand for them to be comfortable passing the already-passed Senate version.  (That way, the House members can assure they get what they want in the Reconciliation bill, because any revenue bill must start in the House.)
• Senate passes the same Reconciliation bill (though, right now, it is doubtful the Senate can muster even the 51 needed votes). The House then passes the previously-passed Senate overall health reform bill (no need for another vote in the Senate, so Brown is irrelevant).
• The bill goes straight to the President's desk and is signed into law in 24 hours.

The House Reconciliation bill would have changed the parts of the Senate bill (such as abortion and public option) that the House wanted. This scenario relies on wishful assumptions at several key steps, but it is very clever, and could work. (The deadline for a Reconciliation bill is April.)

The plan all depends on how skittish voters have made each and every Congressmen to just drop health reform and/or not proceed on anything like the current plan, and to definitely stop the subterfuge tactics such as Reconciliation and secret meetings/deals. This feeling is shared by both disappointed liberals and conservatives. So, it is still very important for constituents like you and your clients to tell your Representatives and Senators (and candidates) what you think.

Anti-Trust Insurance Exemption

Meanwhile, Speaker Nancy Pelosi hopes to push to pass a bill to repeal the anti-trust exemption for insurers. Insurers have indicated that it would not be devastating to their business, and others predict the net effect would be to raise costs for patients and payers. The main reason for this legislative action would be that even if health reform seems to have been bungled by Congress itself, they can look rough and tough and get in at least one slap at the insurance industry whom thy have vilified. Again, it is doubtful that even this anti-trust gambit can pass the Senate.

While Pelosi is pursuing this isolated issue, she is also saying that piecemeal or incremental reform is worthless. The statement is interesting, because she implicitly acknowledges that many of the reforms (such as simply banning pre-ex discrimination) would raise costs. Consequently the net effect of her statement is to say that without all the government goodies, health reform will cost everyone more.

In the meantime, President Obama went virtually silent about health reform in the first week or so after the Massachusetts election, but now the rhetoric is laid back as if things are on track, and the American people simply haven't had enough time to come to know and love the health reform bills.

Please take note for future reference: The only option not getting any serious thought is re- drafting a bill from scratch. Part of the hesitancy in this case is because they worry about having something that fiery reaching a vote just weeks before election day. However, the more important thing to notice is  that once Congress writes something down in a major bill, everyone, including Congressmen, and lobbyists and associations on all sides of the bill restrict their focus of possibilities only to what is in the bill. For example, in the Clinton health reform bill, all discussion ended up on the one-and-only choice whether it would be employers below 500 lives or 100 lives forced into local pools. So, be aware of this self-imposed tunnel vision in Washington DC. It is very hard to break.

Pay Attention to States

With the vacuum caused by the apparent death of federal health reform, states are jumping in  (or picking up were they were a year ago) on their own health reforms. You may smugly think that ERISA preemption exempts your plans from state laws. Not completely! ERISA preemption only applies to state INSURANCE laws, and applies to laws that impact administration decisions of the plan (and courts seem to apply a more and more narrow definition of that). So, if a state health reform is part of the state's health laws, or applies to employment law, or to individuals, or to medical providers, or is in tax law, etc, then ERISA preemption is very iffy and can take years to determine. So don't assume ERISA is a free pass.

Top

SIIA's Political Action Committee Strengthens Presence in Washington

MyHealthGuide Source: The Self-Insurance Institute of America (SIIA), 2/1/2010, www.SIIA.org

As the Self-Insurance Political Action Committee (PAC) completes its first year of operation coinciding with SIIA's upcoming Legislative & Regulatory Conference March 10-12 in Washington, DC, SIIA members should be encouraged to know that it has strengthened the association's Washington, DC presence while raising the profile of the self-insurance/alternative risk transfer industry.

"Through the PAC we have been able to build relationships with Members of Congress and their key staff members that would not have been available to us any other way," according to SIIA Chief Operating Officer Mike Ferguson. "The PAC has enabled SIIA to participate in a significant number of fund-raising events this year for Congressional Members of both parties who are involved with our issues."

In a recent fund-raising event for Sen. Ben Nelson (D-NE), one of SIIA's lobbyists reported that the senator's comments indicated "strong support for continuing the employer-system, specifically maintaining self-insurance in its current form. He appears to be a strong ally in Congress for our industry."

As a result of being able to build a stronger relationship with the senator and his key staff members at such events, SIIA's healthcare expertise has been utilized for the Senator's position statements; furthermore the Senator has accepted our invitation to speak at the Legislative & Regulatory Conference.

SIIA has also led two fund-raising events for Sen. John Tester (D-MT) and Rep. Dennis Moore (D-KS) who both stated that they will introduce bills in their respective Committees that would modernize the Liability Risk Retention Act (LRRA) and expand coverage to include commercial property, in accordance with SIIA's position.

"We are also able to leverage up the financial impact of fundraising events by inviting other like-minded organizations to attend along with us," said SIIA Director of Government Relations Cliff Roberti. "This extends and amplifies SIIA's reputation among members of Congress, their staffs and our colleague organizations," he continued.

SIIA's PAC has also supported South Carolina State Senator David Thomas who is running for U.S. Congress. Senator Thomas attracted SIIA's support as he is widely acknowledged to be the legislative champion of South Carolina's captive insurance industry.

Additional information about the Self-Insurance PAC by clicking here.

About SIIA

The Self-Insurance Institute of America, Inc. (SIIA) is a dynamic, member-based association dedicated to protecting and promoting the business interests of companies involved in the self-insurance/alternative risk transfer (ART) industry, both domestically and internationally.  Visit www.SIIA.org.

Top

Federal Court Rebuffs Insured's Efforts to Discover Attorney-Client Communications Occurring Prior to Claim Denial in Advance Funding Stop Loss Contract Dispute

MyHealthGuide Source: Tom Croft, Esq., King & Croft LLP, 2/4/2010, www.StopLossLaw.com

Case: Galion Community Hospital v. The Hartford Life & Accident Ins. Co., No. 1:08-cv-1635, in the United States District Court for the Northern District of Ohio, Eastern Division (1/29/2010)  Court's Opinion.

Hartford, the stop loss carrier, allegedly denied approximately $600,000 in claims submitted for reimbursement and/or advance funding by the Hospital's TPA, MedBen, between December 26 and December 31, 2007. The stated rationale for the denials was a provision in the advance funding endorsement that required advance funding requests to be received at least two weeks prior to termination of the contract. Specifically, the endorsement provided:

"If the agreement terminates, Your request for advance reimbursement must be received by Us prior to 14 days before the date agreement terminates."

Initially, Hartford, through one or more of its alleged agents (also named as defendants), apparently denied both claims for reimbursement of plan benefits already paid as well as claims for which advance funding had been requested. However, Hartford soon reversed itself and appears to have paid the claims that were not advance funding requests.  The ultimate dispute on the merits looks as if it will turn on whether the Hartford stop loss policy "terminated" or not on December 31. If so, it would appear that the Hospital's claims are not reimbursable; if not, it appears that they are.

When is Stop Loss Contract Termination?

The "termination" question is not as clear as it might first seem. In the motion that is the subject of the Court's opinion, the Hospital argues that the stop loss contract never "terminated," but instead simply expired of its own terms on December 31. Thus, the Hospital reasons, the 14 Day Rule regarding advance funding requests (quoted above) does not apply, and the Hospital's advance funding requests were timely made. [Note: The Hartford policy attached to the Hospital's Amended Complaint in this case has unusual termination provisions, arguably requiring notice of a specified number of days depending upon the reason for the termination and the party declaring it. In my experience, expiration of the policy term is typically listed as an event causing a termination, and limitations on advance funding are usually stated in terms of "no advance funding within the last 30 days of policy period" or something similar. The atypical language used here may be the root of the trouble].

One of the exhibits attached to the Hospital's motion is a copy of a March 5, 2008 letter to MedBen from Hartford , wherein Hartford quotes a letter allegedly emailed from Hartford to MedBen on April 4, 2007:

"The Hartford is withdrawing all previously issued new business and renewal quotes for policies with an effective date of July 1, 2007 and later and will not be renewing any existing stop loss business thereafter."

In its brief, the Hospital nevertheless insists that the above did not constitute notice of a termination, but instead simply a non-renewal. Not surprisingly, we have a case where semantics may dictate the substantive outcome, the metaphysical difference between "termination" and "expiration," if any, ruling the day.

Attorney-Client Communications Discoverable?

But none of the foregoing was addressed or decided by the Court in its January 29, 2010 opinion, nor did the parties request that it be. Instead, at issue was the discoverability of communications between Hartford and its attorneys prior to the denial of the claims.  Under a leading Ohio case, Boone v. Vanliner Ins. Co., 744 N.E.2d 154 (Ohio 2001), pre-denial attorney-client communications were held to be discoverable if they involved coverage issues and there were allegations in the case of bad faith denial of coverage. The Hospital had asserted bad faith claims, and thus argued its entitlement to the documents at issue.

In response, Hartford and the other defendants pointed out that the Ohio legislature had amended the statute governing privileged communications in response to the decision in Boone to require that a plaintiff attempting to discover otherwise privileged material from an insurer in a case with bad faith claims must first make a prima facie (pronounced "prim-a face-ya" here in the South) showing of bad faith before obtaining access to the material.

What, a normal human might ask, is a prima facie showing? Without saying what one is or how the Hospital failed to make it, the Court denied the motion, thus protecting the communications at issue from discovery.

Interpreting the Court's Action

I will attempt this less-than-satisfactory answer: one makes a prima facie case when one alleges sufficient facts in sufficient detail which, if later proved, would entitle one to recover under applicable law. Asserting "legal conclusions" is not enough. Thus, simply alleging that an insurer is guilty of bad faith (or orneriness of a disproportionate nature, malice, or just plain meanness and being contrary) does not make a prima facie showing, and does not get one behind the cloak of attorney-client privilege.

Truth is, at the pleading stage, the "prima facie" test is essentially a smell test: is there enough smoke here to suggest the reasonable possibility of a fire, or is the complaint smoke and mirrors only? Reducing the Rule of Law to such banalities might seem offensive to some, and disillusioning to others, but I submit my description is generally accurate. It's just that they don't teach olfactory science in law school.

About Tom Croft and King & Croft LLP

Tom Croft is an attorney with the firm of King & Croft LLP, Atlanta, Georgia. He has a national practice, consulting with and representing stop-loss carriers, MGUs, and other entities in matters arising in the self-funded employee benefit plan industry. Tom is a magna cum laude graduate of Duke University (1976) and an honors graduate of Duke University School of Law (Order of the Coif, 1979), where he served as Associate Dean and Senior Lecturer. He is a regular contributor to The Self-Insurer Magazine's "From The Bench" column. Tom is licensed in Missouri (1979), Texas (1985) and Georgia (1992); he associates with local counsel in other jurisdictions when appropriate. Contact Tom at 404-577-8400, tac@king-croft.com or visit www.StopLossLaw.com and www.king-croft.com.

Top