MyHealthGuide Newsletter
News for the Self-Funded Community

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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

Yottaflow & KU Software Formalize Partnership to Streamline Stop Loss

MyHealthGuide Source: Yottaflow, 8/28/2015,

CLEVELAND -- kusoftware, developer of The Ugan System, and Yottaflow are excited to announce a formal partnership with the goal of simplifying stop loss for TPAs, MGUs, and Carriers. Through this partnership, Yottaflow and kusoftware will coordinate and automate data exchange between TPAs and MGUs/Carriers in connection with all stop loss processes including RFPs, potential claim/trigger diagnosis notifications, and claim submissions. Leveraging the strengths of both companies, Yottaflow and kusoftware will deliver an integrated system that focuses on simplicity and ease of use while providing powerful features at a competitive price.

"We want to streamline work for those involved with stop loss on a daily basis. At the same time, we want to provide much needed visibility into the claim submission and RFP process", said Mike Farley, Yottaflow's President. Kevin Ugan, kusoftware's President adds "the interaction between TPAs, MGUs, and carriers is too cumbersome and time consuming and we aim to make it easier for everyone."

This partnership is more than just a handshake agreement. As part of the arrangement, kusoftware has acquired an equity stake in Yottaflow.

About kusoftware & Yottaflow

kusoftware is one of the leading developers of complete, integrated underwriting and administration software systems for MGUs and Carriers. The company, based in Atlanta, Georgia, has been developing custom software for businesses since 1989. Visit

Yottaflow is a web-based software application that simplifies the way TPAs track and manage stop loss RFPs, claims and notifications. Yottaflow is based in Cleveland, Ohio. Contact Mike Farley at, 216-245-7160 and visit


United Claim Solutions (UCS) Offers Dramatic Savings through its High Dollar Claim Solutions

MyHealthGuide Source: United Claim Solutions (UCS), 8/28/2015,

PHOENIX, AZ -- United Claim Solutions (UCS), an innovative Medical Cost Reduction and Claims Flow Management company has developed a proven program that generates dramatic savings on high dollar claims including Dialysis, SurgiCenters, Air Ambulance and Behavioral Health Facilities.

"We've recognized that the utilizing the status quo process of accessing Wrap and Supplemental PPOs to obtain discounts on specific high cost services and associated providers is no longer an option. Consequently, we've developed an innovative approach that yields significantly greater savings on high cost services including dialysis, surgicenters, air ambulance and behavioral health facilities," said Joshua Carder, President. "Depending on the service and the provider we're securing savings that range from 50-90% off billed charges."

UCS manages all provider inquiries on behalf of its Clients, making the High Dollar Claim Solution a simple and effective program for Clients to implement.

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, labor organizations, reinsurers, 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

For more information contact Corte Iarossi, VP of Sales & Marketing at 866-762-4455 x 120, or via email at Visit


People News

Self-funding Leader Gary Tipton Passes

MyHealthGuide Source: 8/17/2015, Weed-Carley-Fish
Gary Tipton
Gary Tipton
November 27, 1944  - August 17, 2015

Lakeway, TX -- Gary Harlan Tipton, 70, of Lakeway, Texas died on Monday, August 17, 2015 following a year-long brave battle with cancer. Gary was born on November 27, 1944 in Temple, Texas to Troy Harlan Tipton and Geneva Baker Tipton.

Gary was a visionary when it came to the design and implementation of new health insurance models. While at Boon-Chapman in the late 70's, Gary worked with the City of Austin and Bob Spurck to develop the first self-funded health insurance program for municipalities in Texas. He developed many Physician Hospital Organizations in the 80's. Gary also found time to expend his talents as the editor of Texas Times magazine and dabble in the candy factory business. Gary's creative mind, contagious smile and tremendous sense of humor will be sorely missed.

Gary graduated from Waco High School and played football for the University of Texas Longhorns from 1963 to 1965. While in high school, Gary was selling life insurance after receiving special permission to take the licensing test before the legal age of 18. He served in the Texas National Guard as a Mess Steward and Jump Master for the 3rd Battalion, 143rd Infantry from 1968-1971. Upon receiving his Bachelor's degree from Baylor University, he went to work selling life insurance for Texas Life achieving a place at the Million Dollar Round Table. He then began working in the Health Insurance Industry as an insurance consultant. He has resided in Waco, Austin, San Antonio, Canyon Lake, and, most recently, Lakeway, Texas.

His hobbies and interests included hunting, fishing, boating, riding his Harley and mountain bike, cooking, traveling, and wood working. He was quick to give a helping hand to anyone who needed it. Gary had a way of lightening the mood during social gatherings. His positive energy, fascinating stories and good-hearted character permeated the room often making him the center of attention. One of Gary's most admirable attributes was his ability to develop strong bonds with people in such a short amount of time. He had a way of communicating not only with people, but also dogs. He had a very special place in his heart for his companion, Bullet. More than the activities themselves, he loved the opportunity to get together with family and friends over great food, a few beers, and Fox News in Tip's Tavern on Canyon Lake.

As you all know, Gary had very strong opinions about politics and life in general, and his last wishes were no exception. He insisted there would be no formal funeral service. Instead he requested that as friends and family come together at future gatherings, they remember him by sharing memories. We would like to use this website to post your stories or pictures of Gary as a tribute to his life. Please join in the celebration and send your stories and pictures to

In lieu of flowers, the family requests that donations be sent to Hospice Austin or a charity of your choice.

He fought the good fight and now the words of Isaiah 40:31 apply, "but those who hope in the Lord will renew their strength; they will soar on wings like eagles, they will run and not grow weary, they will walk and not be faint."


Munich Health North America Announces the Hiring of Dawn Carlsgaard

MyHealthGuide Source: Munich Health North America, 08/24/2015,

Princeton, NJ -- Munich Re announced that Dawn Carlsgaard has joined the Munich Health North America reinsurance team as a Managed Care Underwriter in the Managed Care and Reinsurance Solutions unit.

Dawn brings over 20 years of experience in underwriting and account management experience in the healthcare reinsurance industry. Dawn will be based in the Minnetonka, Minnesota office, where she will be responsible for underwriting and expanding our Medical Excess line of business. She will monitor the in-force coverage, as well as develop and enhance strong relationships with the brokerage community.

Ken Wojack, Vice President of HMO Re Underwriting, says: "We are excited to have Dawn join our staff in the Minneapolis area. Her technical expertise and experience in underwriting and account management will help Munich Health grow this key line of business."

Dawn has a strong background in managed care underwriting, beginning at Fortis, and then working at ING Re, StarLine Group, and IOA Re, gaining experience in underwriting HMO Reinsurance and Provider Excess insurance and creating lasting relationships with the brokerage community.

About Munich Health

Munich Health is one of three business segments of Munich Re. Here all international health care business in insurance and reinsurance operations, as well as related services are pooled under the Munich Health brand.  Contact Steve Fedele, Marketing Manager, at (609) 243-4238, and visit


Data Dimensions Welcomes R. Ted Hailer as Program Director

MyHealthGuide Source: Data Dimensions, 8/25/2015,

JANESVILLE, WI -- Data Dimensions is proud to announce the addition of R. Ted Hailer to its Project Management Team as a Program Director.

Before his arrival at Data Dimensions, Hailer most recently served as an Insurance Systems Consultant at Pro Unlimited, where he worked closely with a number of major Property and Casualty firms on their insurance systems. Before that, Hailer worked for 26 years in various senior-level positions at both Kemper and Unitrin Insurance, including Program Manager, Senior Project Manager and Manager of Business Transformation Technology.

In addition to his business experience, Hailer has a strong military background, having served in the United States Army National Guard as a First Lieutenant, Tank Platoon Leader.

"Ted brings a wealth of knowledge and experience from the property and casualty arena to Data Dimensions," said Jon Boumstein, President and CEO. "He will be a strong addition to the Data Dimensions team, mentoring his colleagues, providing insight as a subject matter expert and assisting with business development opportunities in the insurance sector."

About Data Dimensions

Since 1982, Data Dimensions has been helping clients better manage business processes and workflows by bridging the gap of automation, technology, and physical capabilities. As an innovative leader in the area of information management and business process automation, we provide a complete range of outsourcing and professional services including mailroom management; document conversion services; data capture with OCR/ICR technologies; physical records storage and electronic retrieval services through our state of the art Tier III data center. Contact Will Pfeifer, Marketing Coordinator, at, 800.782.2907 and visit

Data Dimensions is a portfolio company of HealthEdge Investment Partners, LLC. HealthEdge is an operating-oriented private equity fund founded in 2005. HealthEdge's investment team has over 100 years of combined operating experience as operators and investors. For more information on HealthEdge, visit


Axia Strategies Has an Immediate Opening for a Director of Pharmacy Analytics

MyHealthGuide Source: Axia Strategies,  8/27/2015,

Axia Strategies is experiencing rapid growth in our pharmacy benefits management practice, a specialty consulting area supporting our clients in the assessment, selection and ongoing management of the PBM's utilized to address pharmaceutical cost trend. As a valuable member of our team, the Director of Pharmacy Analytics will be responsible for the coordination of pharmacy management analytical projects as conducted by Axia Strategies' pharmacy consulting practice located in Minneapolis, MN.

Essential Duties & Responsibilities

  • Coordinate all aspects of client-and vendor related project management with the Account Executive to ensure client satisfaction and timely project delivery.
  • Lead role in management and coordination of RFP and client PBM negotiation projects.
  • Coordinates the assignment of all projects across the data analyst team.
  • Identify areas for improvements and implement those improvements.
  • Assist in the identification of new products and implementation of those products.
  • Meet with clients in person and telephonically to determine needs, provide data, and solve problems
  • Develop and provide technical leadership.
  • Analyze client and prospect data for trends and issues.
  • Manipulate and work with spreadsheets to gather and query data needed for Rx claims analysis.
  • Provide Rx trending and technical expertise to clients.
  • Provide training, education, and guidance to Account Managers


  • College degree or equivalent job related experience required
  • Knowledge of pharmacy benefit industry
  • Effective time management, written and verbal skills
  • Ability to work well with team members, maintain confidentiality, remain open to others' ideas and exhibit a willingness to try new things
  • Ability to demonstrate accuracy and thoroughness and monitor own work to ensure quality
  • Advance MS Office and SQL skills
  • Advance data analysis, analytical, problem solving skills

Interested candidates should email their resume to .

About Axia Strategies

Axia Strategies is a Minneapolis-based managed care consulting and brokerage firm, focused on the development of effective cost containment solutions on behalf of our health plan, reinsurance and stop-loss carrier clients. Established in 1998, Axia has developed marketplace-leading cost containment support services in pharmacy benefit management, catastrophic claim solutions and specialized medical management approaches. Visit


DialysisPPO has an Immediate Opening for a Regional Sales Manager (Locate Anywhere)

MyHealthGuide Source: Laura J. Haffner, Executive Vice President, DialysisPPO 8/25/2015,

Regional Sales Manager Midwest, Mid-Atlantic or Southwest
DialysisPPO is seeking a sales professional that understands what a sales cycle is and how to appropriately and professionally prospect, approach, present, follow up, and close a deal. At least ten years' experience in Medical Stop Loss is strongly preferred, Cost Containment experience a plus.

DialysisPPO has been in business since 2006. We have a stellar reputation in the cost containment and management of End-Stage Renal Disease ("ESRD") claims. We are the only company with a patented process. We provide unmatched high-level cost containment services to self-funded companies of all sizes that need and want to manage one of the highest cost drivers in their Medical programs, ESRD claims.
We are a very unique and boutique firm, and are looking to place Regional Sales Managers in various parts of the US. The Midwest is preferred; however, for the right candidate, we will consider all areas of the country. The individual will report to the Executive Vice President, located in Seattle, WA. The position will be working from home with 25-50% travel in a defined territory. We will provide full training, necessary materials, sales leads and data in order that our Regional Sales Managers will be able to prospect, present and educate any potential client about DialysisPPO's unique value proposition.

Job Qualifications

  • Minimum of 10 years of experience in sales of products and/or services in the Medical Stop Loss, employee benefits or cost containment space
  • Existing contacts in the TPA, stop loss, retail broker, Union verticals strongly desired
  • Professional designations such as CEBS are desirable
  • Disciplined, experienced, motivated self-starter
  • Sales, communication and relationship-building skills
  • Microsoft Office proficiency required
  • Must clear a background check
  • College degree preferred

To be considered for this position, candidates must have previous work experience in sales and an understanding of products and verticals including Medical Stop Loss, Third Party Administrators, Employee Benefits, Retail brokers, etc. Must maintain own medical coverage; no employee benefits or 401(k) plan currently available.

If interested please email us your resume to Once we receive your resume we will follow up and let you know if you're being considered for the position. We will also include more information about our firm's services and expertise. We look forward to hearing from you.

About DialysisPPO

DialysisPPO helps group health plans and their partners manage the exceptionally high cost of dialysis cases for the treatment of End-Stage Renal Disease. Our patented program enables plans to capitalize on the unique Medicare reimbursement aspects of this costly disease, yielding average client savings of $590,000 per dialysis case annually. Visit


HIIG Elite Underwriting Has an Immediate Opening for a Chief Actuary

MyHealthGuide Source: Houston International Insurance Group (HIIG), 8/17/2015,

Join our growing team! Houston International Insurance Group (HIIG) made a strategic acquisition to acquire Elite Underwriting and is looking to aggressively expand. We are excited to be growing our Accident and Health division. At HIIG-Elite, we consider every employee to be a valuable part of our company. Our continued success is a direct result of our team's industry expertise and hard work.

This position of Chief Actuary can be located in in our Malvern, PA, Indianapolis, IN, Wakefield MA or Houston, TX locations.

Essential Duties and Responsibilities

  • Lead pricing, reserving, product development and forecasting for Accident & Health products. Experience with voluntary lives and supplemental health products a plus.
  • Work on pricing models, reserve studies, management reporting, financial forecasting, business strategies and other assignments.
  • Develops the basis for and analyzes advanced actuarial studies for health or group insurance (e.g. morbidity, mortality, lapses, expenses, financial results, selection, secular trends, claims utilization, cost factors and reserve adequacy) to determine premiums, rates, coverages, reserves and financial statement liabilities
  • Works in conjunction with other departments in response to changing market conditions and net market opportunities.
  • Leads special projects and is involved in evaluation of acquisition targets.
  • Provides consultation of data to various audiences; able to communicate technical data to audiences with various levels of understanding.
  • Participate in Board level presentations about current business and future opportunities.

HIIG Elite offers

  1.  A competitive base salary
  2. Leadership development through individualized support and mentoring
  3.  Medical benefits, STD/LTD, Life, Dental, Vision, 401k, PTO

Interested candidates should email their resume to

About HIIG

HIIG is a Houston based, rapidly expanding insurance group that provides creative solutions for our clients' specialized needs. HIIG writes business throughout the USA and Internationally through its underwriting divisions that include Accident & Health, Construction, Energy, Professional, Transactional Property, and other Specialty business.

HIIG Elite is our Accident & Health Division and we are seeking an experienced Chief Actuary who is self-motivated and possess a strong entrepreneurial spirit...let us hear from you !! We hope you will consider joining the Team. Visit


Market Trends, Studies, Books & Opinions

Waking Up to the Opportunity of Self-Funded Employee Health Benefits

MyHealthGuide Source: Carol Berry, CSFS , 8/24/2015, American Journal of Managed Care (AJMC)

The self-funded employee health benefits market is a sleeping giant.

Programs in which companies finance their employees' healthcare with their own assets are becoming increasingly prevalent, as employers seek ways to reduce ever-escalating expenses, manage risks, increase flexibility of their plans, and tailor plans geared toward what their workers really want and need, all within the confines of the Affordable Care Act (ACA).

With organizations' healthcare expenses are poised to jump by almost 7% in 2015, according to PricewaterhouseCoopers' Health Research Institute, self-funding can be an alternative to help a company control how much it spends on employee health benefits, while providing workers with quality healthcare.

Almost 95% of US companies with at least 5000 employees currently self fund their health benefit plans. However, the industry that was once mostly thought to be only the domain of large companies, like Walmart, Microsoft, and Starbucks, is now changing. Today, the self-funded market, regulated by the Department of Labor and under the protection of the Employer Retirement Income Security Act, now includes nearly 60% of US employers of all sizes.

The ACA is fueling the proliferation of self-funding by adding new costs on fully insured plans and eliminating the risks typically associated with self-funding. Many self-funded healthcare plans are exempt from new taxes, fees, and restrictions placed on fully insured medical plans by the ACA. So employers with strong financials and stable work forces are increasingly looking at transitioning to self-funding their employee benefits.

Some of the benefits that can be realized by developing a self-funded health benefit plan include:

  • Plan design flexibility
  • Premium and healthcare cost savings
  • Cost transparency
  • And importantly, the availability of detailed analytics, which provide information on fees, expenses, and costs not usually able to be provided by fully insured plans

Self-funded plans hold down healthcare costs better than fully insured plans. Once an employer has developed its self-funded program, with careful planning and administration, it can expect to realize, on average, a 5% to 15% savings over participating in a fully insured plan.

We are often asked, "How does an employer interested in self-funding the healthcare benefits pursue it as an option?" If a company determines self-funding may be appropriate, company leaders should:

  1. Engage an insurance broker or health benefits consultant to guide the process;
  2. Do a cash flow and risk analysis to determine the monetary resources available and the employer's risk tolerance;
  3. Identify the plan benefits desired;
  4. Identify the amount and type of stop loss coverage desired to protect against catastrophic or unpredictable losses;
  5. Discuss the types of additional benefits desired: medical/case management, dental, vision, pharmacy benefit manager, flexible spending account, wellness, etc.;
  6. Discuss the type of provider network needed;
  7. And last, but certainly not least, companies moving to self-funding will need to contract with a reputable third-party administrator (TPA).

This TPA will work with the employer's broker/consultant, to bring all the diverse pieces together in a cohesive benefit package and will provide the administrative services, systems and process to implement the self-funded plan. There are many important players in the self-funded community, including stop loss carriers, networks, medical managers, wellness companies, legal counsel, compliance companies, underwriters, audit firms, healthcare systems, brokers, human resource managers and consultants. Selecting the right TPA is a critical addition to the team and is critical to the success of an employer's self-funded plan.

About the Author

Carol Berry, CSFS is the chief executive officer for the Health Care Administrators Association (HCAA), and has more than 35 years' experience in the healthcare and software industries. She has held a variety of executive positions in self-funding, managed care, managed behavioral health, and group medical insurance, including principal of Lockhurst Consulting, director of account services for Coastal TPA, and senior vice president of HealthLogic Systems Corporation.


Legislative & Regulatory News

State Law Claim for Invasion of Privacy Escapes ERISA Preemption

MyHealthGuide Source: Mark S. Thomas,  8/27/2015, Williams Mullen

Case: Rose v. HealthComp, Inc., No. 1:15-cv-00619-SAB (E.D. California, August 10, 2015)  Court's Ruling

Article referred by John H. Eggertsen, Attorney at Law, Eggertsen Consulting, Inc.

A federal court recently held that the plaintiff's claims under state law survived ERISA preemption, and remanded the case to state court to determine the plaintiff's claims for invasion of privacy and unfair business practices arising from the administrator's disclosure of her medical records to her employer. While rooted tightly to its facts, above Rose illustrates some of the limits to the otherwise broad reach of ERISA preemption.


The plaintiff ("Rose") was employed in California by Harris Ranch Beef Company ("Harris Ranch") for over eight years, to late 2012, and was enrolled in Harris Ranch's self-insured employee health plan. The defendant, HealthComp, Inc. ("HealthComp"), was the plan's third-party administrator and, in that fiduciary role, provided case management services. As part of these services, HealthComp notified Harris Ranch when HealthComp saw an employee's health costs rising, and also assigned a nurse case manager to work with an employee in an effort to hold down health costs.

Rose suffered from medical issues for years, leading in December 2011 to hospitalization for treatment and diagnosis of liver failure. Her doctors determined that she needed a liver transplant and placed her on a transplant waiting list. Rose alleged, in this case, that in March 2012, without her permission, HealthComp notified Harris Ranch of her medical condition and need for a liver transplant. HealthComp assigned Rose a nurse case manager, and Rose signed a medical release form for that case manager; Rose alleged in this case, however, that she was not told that her medical information would be shared with her employer.

In December 2012, HealthComp sent Harris Ranch a report that Rose's need for an expensive liver transplant had increased. Harris Ranch terminated Rose shortly after it received that report, and HealthComp closed its case management file on Rose. Rose later filed a lawsuit against Harris Ranch. HealthComp then reopened its file; Rose alleged, in this case, that HealthComp used its prior medical authorization release to then review her medical records and furnish information to Harris Ranch.

Rose then sued HealthComp under California law in California superior court, alleging invasion of privacy and unfair business practices arising from unauthorized disclosures of her medical information to Harris Ranch. HealthComp removed the case to federal court, asserting that the claims were preempted by ERISA. Rose then filed a motion to remand the case to state court.

The Court's Ruling

The federal courts have long held that the scope of ERISA's preemption of state law is very broad in order to achieve the Congressional goal of providing a uniform regulatory scheme for ERISA-governed employee benefit plans. All state law claims that come within the scope of ERISA preemption are displaced by the federal statute and converted into federal claims under ERISA's civil enforcement provision, section 502. That is, the claimant then has the remedies ERISA's section 502 would allow, if any, and not the remedies provided under state law. The question in Rose was whether the plaintiff's state law claims were subject to that broad preemptive reach.

The Rose court held that under the U. S. Supreme Court's decision in Aetna Health Inc. v. Davila, 542 U. S. 200 (2004), and the U. S. Court of Appeals for the Ninth Circuit's subsequent decision in Fossen v. Blue Cross & Blue Shield of Montana, Inc., 660 F.3d 1102 (9th Cir. 2011), the district court had to apply a two-part test to determine whether Rose's state law claims were preempted.

  1. Under that test, a state law claim would be preempted if, first, the individual, at some point in time, could have brought the claim under ERISA section 502(a)(1)(B)(for civil claims by plan participants and beneficiaries to recover plan benefits, obtain a declaration of rights under the plan, etc.), and,
  2. Second, there is no other independent legal duty implicated by the defendant's actions.

The Rose court decided that the case met the first part of the Fossen test. For comparison, the court noted the holding of the U. S. Court of Appeals for the Fourth Circuit in Darcangelo v. Verizon Communications, Inc., 292 F.3d 181 (4th Cir. 2002). The Darcangelo court held that "alleged misconduct by an administrator that was clearly undertaken in the course of carrying out duties under a plan" would be preempted by ERISA, but if the administrator obtained an employee-participant's medical information and informed the employer solely to assist the employer in determining whether the participant was a threat to her co-workers, then state law claims arising from that disclosure would "not be related to the plan". In Rose, HealthComp obtained Rose's medical information while performing case management duties under the plan, and then disclosed them to the employer (improperly, according to Rose), and Rose could thus have alleged a breach of HealthComp's plan fiduciary duties and pursued a claim under ERISA section 502(a). This satisfied the first prong of the Fossen test.

Regarding the second part of the test, however, Rose asserted claims arising under California's right of privacy that arose independently of either ERISA or the plan terms. The court found that the state law claims did not arise "but for" the administration of the ERISA plan, and those claims could have been brought even if Harris Ranch's plan had not existed. The fact that HealthComp would not have obtained Rose's medical information without the existence of the Harris Ranch plan, did not create a sufficient relationship with the plan under the Ninth Circuit's cases to justify preemption.

Because Rose's claims did not satisfy both prongs of the Fossen test, the court granted Rose's motion to remand the case back to the state court for further proceedings.

The Significant Lesson

While each of the federal circuits will have its own case precedents interpreting the Supreme Court's Davila holding, the ruling in Rose is representative of the preemption analysis. It also points up the seriousness of facts alleging the improper use of a participant's personal medical information and the potential exposure of plans and their fiduciaries when handling such information in this era of heightened sensitivity to personal data disclosures. Rose thus indicates some limits to ERISA's broad preemption doctrine in that scenario.

About the Author

Mark Thomas is a partner in the firm's Litigation Section. He represents individuals and businesses in connection with ERISA and other employee benefits disputes, trust litigation, lawsuits and registrations to protect trademarks, copyrights and other intellectual property, and complex business litigation. In addition, he counsels clients on the administration of employee benefit plans.  Visit


ERISA Administrative Appeal Denial Letters Must State Plan-Imposed Time Limits

MyHealthGuide Source: Stacey Cerrone and Russell Hirschhorn, 8/28/2015, Proskauer Rose LLP

Case: Mirza v. Insurance Administrator of America Inc., 2015 WL 5024159 (3d Cir. Aug. 26, 2015).  Court's Ruling

The Third Circuit recently held that ERISA administrative appeal denial letters must include plan-imposed time limits for commencing a lawsuit challenging the claim denial, and the failure to provide such notice warranted setting aside the plan's limitation period.

The ERISA claims regulation provides that adverse determination letters must provide a "description of the plan's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action" for benefits. 29 C.F.R. 2560.503-1(g)(1)(iv).

Court's Ruling

Consistent with the First and Sixth Circuits' rulings on this issue, the Third Circuit determined that the regulation's "time limit" notice requirement applies not only to periods pertaining to when a participant may file an administrative appeal, but also to a plan-imposed limitation period for commencing a lawsuit after an appeal is denied.

In so ruling, the Court reasoned that not requiring such notice would permit administrators to "hide the ball" because participants are more likely to read and rely on adverse determination letters than lengthy plan documents. Having found that such notice is required, the Court determined the proper remedy was to set aside the plan's limitation period and to replace it with the most analogous state law period, which the parties agreed was New Jersey's six-year limitation period applicable to breach of contract claims.

Proskauer Perspective

Given that three circuits already have ruled consistently on these issues, plan fiduciaries should make sure that administrative appeal denial letters specifically set forth plan-imposed time limits. Furthermore, given the courts' tendency not to penalize participants for failure to consult SPDs and plan documents when pursuing a claim for benefits, plan sponsors and administrators should consider whether there is other information pertinent to the claims process to which they should affirmatively alert participants when determining claims for benefits.  Visit


Medical News

ICD-10: Coding for Hypertension and Heart Disease

MyHealthGuide Source: Betsy Nicoletti, MS, 8/25/2015, Medscape Business of Medicine, WebMD, LLC

The change to ICD-10 provides the opportunity to more accurately report hypertension, hypertensive heart disease, and hypertensive chronic kidney disease conditions.

Essential hypertension in ICD-10 has only one code: I10. Coders joke that it is the one code they can easily memorize, because a complete ICD-10 code can be up to seven characters long and is alphanumeric. Both 401.1 (benign hypertension) and 401.9 (hypertension, not otherwise specified) will be replaced by I10 -- essential (primary) hypertension.

There are specific codes to describe hypertensive heart disease, hypertensive chronic kidney disease, and hypertensive heart and chronic kidney disease.

  • If a physician determines that a patient has hypertension and heart disease caused by the hypertension, list first the combination code for hypertensive heart disease, either with or without heart failure.
  • If the patient has heart failure, there is a notation to use an additional code from the I50 category to identify the type of heart failure.
  • A patient with hypertension and chronic kidney disease is coded with a code from category I12, hypertensive chronic kidney disease. I12.0 is for hypertensive chronic kidney disease in a patient with stage 5 or end-stage renal disease or I12.9 for hypertensive chronic kidney disease, stage 1 through stage 4.

Coding Options Increase

And of course, add another code to describe the stage of the chronic kidney disease. A coder may assume a causal relationship between hypertension and chronic kidney disease, but may not assume a causal relationship between hypertension and hypertensive heart disease.

If a patient has both hypertensive heart and chronic kidney disease, the coding options increase. Then, select a code from the I13 category. The code indicates whether the patient has heart failure or not, and the stage of the chronic kidney disease. As in the previous situations, use additional codes to identify the type of heart failure and the stage of the kidney disease.


Recurring Resource

Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 8/8/2015)

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

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
Capital /Equity
1. CIGNA     $2,318
  CIGNA Financial Supplement 2014, P.5 12/31/2014
2. Sun Life Financial     $1,034.2
  Sun Life 2/12/2015 Management Discussion of "13% stop loss growth over 2013" of 2013 premium of $915.2M provided by 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+)
$3,903 HCC Insurance Holdings, Inc. Form 10-K
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
Matt Rhenish, President & COO, 2/16/2015
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
Symetra 4Q 2014 Financial Supplement;
Tom Doran, President, Medical Risk Managers, Inc.
6. Voya Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
Joe Keller, Lead Financial Analyst, Voya Employee Benefits,
7. Companion Life > 20 Years   $440
  Philip Gardham, Vice President, Specialty Markets,
8. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
  Independence Holding Company
9. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
10. Zurich North America     $150   Joseph Byers, Zurich North America.
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
  Victor Moran, Second Vice President, Actuarial Operations.  3/6/2015
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $3,388
Mark Nichols, Managing Director.

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
  • 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  


The Value of Self-Funding

MyHealthGuide Source: The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, The Self-Insurance Educational Foundation, Inc. (SIEF has published The Value of Self-Funding.

Self-funding is an important contributor to the financial and physical health of America's wellness future. Self-funding is more than processing claims and receiving premiums, it provides quality coverage and proactive healthcare management for employers of all sizes and industries.

About the SIEF

The Self-Insurance Educational Foundation, Inc. (SIEF) is a 501(c)(3) non-profit organization affiliated with the Self-Insurance Institute of America, Inc. (SIIA). The foundation's mission is to raise the awareness and understanding of self-insurance among the business community, policy-makers, consumers, the media and other interested parties. Visit


Upcoming Conferences

September 10, 2015 - Webinar 2:00 pm ET
Cost-Containment Insights: Partnering to get the solutions you need presented by Sun Life Self-funded employers (and those that are considering becoming self-funded) continue to seek support on how to manage the cost of medical claims. Designed for the third party administrators, brokers and nurse case managers who support self-funded employers, webinar participants will hear from cost-containment expert Mark S. Hartmann, EthiCare Advisors, Inc. CEO and Brad Nieland, Sun Life Stop-Loss Vice President. They'll share insights on the latest medical claim trends and cost-containment best practices that you can use immediately.

September 10, 2015 - Webinar 1:00 pm EST
Predicting the Future of Claims Cost Analysis presented by Advanced Medical Strategies.  Join us for a look at how technological innovation can transform how you approach catastrophic claims.  In this 45 minute webinar you'll learn: How a data-driven approach to processing catastrophic claims will increase efficiency, save time and save money. How to access billed and paid data that gives you increased leverage in negotiations. What technologies are reducing and eliminating the need for outside vendor fees like underwriting, cost containment, and case management. With new treatments and pharmaceuticals, complex claims are in a constant state of re-evaluation and change, so please join us on September 10th for this cutting-edge presentation. Limited seating available. Reservation:

September 14-15, 2015
Texas Association of Benefit Administrators Annual Fall Conference and Membership Meeting. The Conference will be at the Crowne Plaza near The Galleria in Addison, Texas.  Contact Phyllis Campbell at 512-507-7001 and Information and registration:

September 14-16, 2015
Self-Insurance Executive Summit in London with Special Lloyd's Tour presented by Self-Insurance Educational Foundation (SIEF). Join senior industry executives from the United States, the United Kingdom and other major insurance marketplaces to share knowledge and facilitate important professional connections in London. Apex City of London Hotel. Conference information: 800-851-7789 and

September 14-16, 2015
2015 MCRA Annual Conference presented by Managed Care Risk Association. Terranea Resort, Palos Verdes Peninsula, California-overlooks the Pacific Ocean and Catalina Island. Early bird conference fee is $650 through May 18, $750 afterwards. Hotel number is (866) 802-8000 and mention "Managed Care Risk Association". See The mission of the Managed Care Risk Association is to support the health care excess of loss reinsurance and provider excess markets by facilitating information exchange between reinsurers, underwriters, brokers, and cost containment providers.

September 17, 2015 - 1:00 PM (EST) to 2:00 PM (EST)
Phia Case Studies -When Silence is Loud and Assumptions Mean Disaster presented The Phia Group. As employers look to self-fund with increasing frequency, expectations that brokers, vendors, and third party administrators will take on more binding authority are trending as well. Cases where an entity is held liable for failing to uphold a responsibility it didn't intend to adopt are consequently on the rise as well. These recent cases impact how you are (or at least should be) handling claims. Information and Registration

September 22, 2015 - Webinar 9:00 am PT/11:00 pm CT/12:00 pm ET
Snake Oil, Balderdash, and Hogwash: Searching for Truth in the Fraught Legal Landscape of ERISA Today presented by Health Care Administrators Association (HCAA).  Presenter: Josh Sears, founder, Freestone Corporate Law, Chtd., based in Boise, Idaho. Josh's expertise includes ERISA, COBRA, HIPAA, and the Patient Protection and Affordable Care Act.

ERISA has been operating efficiently for many years by providing employers a framework from which to administer multi-benefit programs uniformly across multiple states. But, state-based power-grabs, regulatory gobblely-gook, high-court decisions, the fear-mongering of politicians (and even some misguided folk within our own industry) challenge and threaten to erode the very construct from which it has thrived so successfully for decades. Understanding ERISA and impacts of the ACA on its mandates (for good and ill) is of critical importance so you can assist in protecting this framework and best serve your clients. In order to be the most informed with the current legal challenges facing our Plans with the advent of ACA, this overview will address the following items: ERISA: State by State assault on pre-emption, Federal Legal Developments, Cadillac Tax and whether it is permissible as a non-fiduciary, King v. Burwell decision update, MEC & Skinny Plans, Reference Based Pricing, Brokers competing for your clients (veiled "threat of exposure", wrap documents, compliance).  Webinar Registration:

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

October 18-20, 2015
National Educational Conference & Expo presented by Self-Insurance Institute of America. Program Addresses:

  • The Rise of Private Equity and Venture Capital in the Self-Insurance Marketplace
    Your Company and Its Future - Preparing for a Major Financial Transaction
    How does direct provider contracting work in the context of medical travel arrangements;
    What hospital executives think about self-insured employer payment practices;
    What has been the actual self-insured employer experience with on-site health clinics;
    How self-insured health plans should start preparing for the ACA "Cadillac" tax;
    What venture capital and private equity firms are looking for when considering acquisitions of companies active in the self-insurance marketplace;
    Where all of the "big" health care claims have been coming from;
    The latest ACA compliance news;
    What to do if your plan becomes subject to a DOL audit;
    How do you determine whether reference-based pricing is right for your plan;
  • Additionally, the schedule will include a "mock mediation" session where attendees will have a front row seat to see what happens when a self-insured group, a TPA and a stop-loss carrier have a serious claims payment dispute. This promises to an extremely entertaining and interactive session.

The health care sessions are part of a larger educational program that includes nearly 40 general and breakout sessions related to the broader self-insurance marketplace. This top-notch educational program will be supplemented by the industry's largest exhibit hall and incredible networking opportunities throughout the event. Marriott Marquis, Washington, DC. Call 800-851-7789 and visit


February 9-11, 2016
Executive Forum 2016 presented by Health Care Administrators Association (HCAA). Senator Tom Daschle is opening keynote! Senator Daschle will present "An Insider's View on President Obama's Health Care Policy and Its Future" on Wednesday 2/10/16 from 9:00am - 10:30am.  Caesars Palace, Las Vegas, NV. Room rates: $220 / night plus tax (through 1/15/16).  Call 866-227-5944 and reference Health Care Administrators Association or SCHCA6.

March 7-9, 2016
The Sixteenth Population Health Colloquium presented by HC Conference. Philadelphia, PA and WEBCAST.  Featuring Special Medical Home Track.  Presenters include: Troyen Brennan, MD, MPH, Executive Vice President and Chief Medical Officer, CVS Health, Former Chief Medical Officer, Aetna Inc., Woonsocket, RI.  Bill Copeland, MBA Vice Chairman and US Life Sciences & Health Care Industry Leader, Deloitte LLP, Philadelphia, PA.  Peter R. Orszag, Vice Chairman, Citigroup, Former Director, OMB (Obama), Former Senior Economist, Council of Economic Advisers (Clinton), New York, NY Information and Phone: (800) 503-7439, and 

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

July 13-15, 2016
TPA University 2016 presented by  Health Care Administrators Association (HCAA). Renaissance Dallas, Dallas, TX.

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


February 8-10, 2017
Executive Forum 2017
presented by Health Care Administrators Association (HCAA). Bellagio, Las Vegas, NC.  

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

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


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