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TABLE OF CONTENTS
Castelloe Partners, LLC
View welcome message at http://vimeo.com/118922345 .
About Castelloe Partners, LLC
Castelloe Partners, LLC provides knowledge and business connections to positively affect business. Contact Jerry Castelloe at email@example.com, 704-572-0730 and visit www.castelloepartners.com .
HealthSmart Launches Partnership with Healthcare Bluebook to Provide Price Transparency Tool to Self-Insured Employers
MyHealthGuide Source: HealthSmart, 2/23/2015, www.healthsmart.com
Dallas, TX -- HealthSmart Holdings, Inc. announced that it has entered into a strategic partnership with Healthcare Bluebook, the industry leader in healthcare price transparency solutions. The Healthcare Bluebook tool will allow all HealthSmart's clients and their nearly 900,000 health plan members to make informed decisions based on price, quality and other critical factors when shopping for care. Using benchmarks within Healthcare Bluebook, members can quickly locate health providers that offer the right care at a Fair Price--resulting in real savings for self-funded Plan Sponsors and their employees.
For example, a HealthSmart client plan member who needs an MRI can use HealthSmart's provider locator tool along with Healthcare Bluebook to find conveniently located imaging centers. In a typical market, the contracted price among imaging centers varies significantly--a range of $600 to $2,400 is common. Assuming a 20% member copayment, the cost to the employee would range from $120 to $480, and the cost to the employer would be $480 to $1,960. A significant savings for both the plan member and insurer can result from choosing the lower priced center. To further encourage member shopping, the employer could also choose to waive the copay or pay the member a cash bonus.
"Price transparency is a critical missing link in the healthcare delivery system," said Mark Stadler, HealthSmart's Chief Marketing Officer. "Our partnership with Healthcare Bluebook will help our clients and their employees achieve price transparency and identify and connect with high-value providers."
"Focusing on the true total cost of quality healthcare, rather than just the percent discount off standard prices, furthers our ability to improve member health and reduce healthcare costs," he stated. "Our unique integration of Healthcare Bluebook with HealthSmart systems even enables our customers to offer their members incentives for using high quality, cost-effective healthcare solutions."
Mike O'Neil, Senior Vice President of Strategy and Development at Healthcare Bluebook said, "The idea of shopping for care based on ‘average prices' or network discount percentages is a thing of the past. In order to control the rising costs of healthcare, the focus needs to be on making it simple for employees and employers to identify the highest value providers, based on the true total cost and quality of care."
For more than 40 years, HealthSmart has offered a wide array of customizable and scalable health plan solutions for self-funded employers. HealthSmart's comprehensive service suite addresses individual health from all angles. This includes claims and benefits administration, provider networks, pharmacy benefit management services, business intelligence, onsite employer clinics, care management, a variety of health and wellness initiatives and web-based reporting. The Company's headquarters is in Irving, Texas, with regional hubs throughout the country. HealthSmart's mission is to improve member health and reduce healthcare costs. Contact Mark Stadler, Chief Marketing Officer, at 214.574.1166, firstname.lastname@example.org and visit www.healthsmart.com .
About Healthcare Bluebook
We help consumers save on healthcare expenses while helping Fair Price providers attract cost-conscious consumers. The Healthcare Bluebook is a free resource that shows a Fair Price for healthcare products and services to consumers. Our consumer-friendly tool helps consumers quickly and easily understand what they should pay for the healthcare services they need. Secret pricing practices have contributed to high price differences among providers and have left the consumers and employers paying more for services than they should. Once consumers know what healthcare services should cost, they can find providers that offer the best value. Contact Mike O'Neal at email@example.com, 615 476-7720 and visit www.healthcarebluebook.com.
Summit Re Announces New Relationship with Zurich
MyHealthGuide Source: Summit Reinsurance Services, Inc., 2/25/2015, www.summit-re.com and www.zurich.com
Fort Wayne, IN -- Summit Reinsurance Services, Inc., a managing general underwriter for healthcare reinsurance, announced today that it has established a new strategic relationship with Zurich American Insurance Company, effective July 1, 2015.
The alliance joins Summit Re's strong, customer-focused culture of designing customized risk mitigation solutions for healthcare reinsurance clients with Zurich's wide portfolio of products. The products are underwritten by individual member companies of Zurich North America, rated A+/Superior by A.M. Best.
"We are delighted to be working with Zurich," says Mark Troutman, President. "These are exciting times for the healthcare industry, with new challenges and opportunities evolving daily. Our selection of Zurich followed a significant period of careful deliberation, through which we sought to answer the question of who could put us in the best long-term position to meet our clients' needs in this dynamic environment. In the end, Zurich was the clear winner."
Summit Re clients should see little to no change in their daily operations and reinsurance interactions, as the transition should be transparent. They can, however, look forward to an enhanced solution set as well as access to new products and services available through Zurich's product line.
"Our mission at Zurich is to help our customers understand and protect themselves from risk," says Julie Bobak, Senior Vice President, Zurich Accident & Health -- Specialty Health Profit Center Manager. "Our relationship with Summit Re will allow us to provide our healthcare customers with solutions geared to their needs."
About Summit Re
Summit Re is a managing general underwriter and reinsurance advisor, working with health insurers, managed care plans, and self-funded employers throughout the US. Summit Re helps its clients analyze, manage, and transfer risk to protect their financial stability. As a consultant and advisor, the company works with clients to formulate and implement new products and strategies. Contact Tammy Davis, Director, Marketing Communications, at 260-407-3977 and visit www.summit-re.com.
Zurich Insurance Group (Zurich) is a leading multi-line insurance provider with a global network of subsidiaries and offices in Europe, North America, Latin America, Asia-Pacific and the Middle East as well as other markets. It offers a wide range of general insurance and life insurance products and services for individuals, small businesses, mid-sized and large companies as well as multinational corporations. Zurich employs about 60,000 people serving customers in more than 170 countries. The Group, formerly known as Zurich Financial Services Group, is headquartered in Zurich, Switzerland, where it was founded in 1872. The holding company, Zurich Insurance Group Ltd (ZURN), is listed on the SIX Swiss Exchange and has a level I American Depositary Receipt program which is traded over-the-counter on OTCQX. Visit www.zurich.com.
In North America, Zurich is a leading commercial property-casualty insurance provider serving the global corporate, large corporate, middle market, specialties and programs sectors through the individual member companies of Zurich in North America, including Zurich American Insurance Company. Life insurance and disability coverage issued in the United States in all states except New York is issued by Zurich American Life Insurance Company, an Illinois domestic life insurance company. In New York, life insurance and disability coverage is issued by Zurich American Life Insurance Company of New York, a New York domestic life insurance company. Visit www.zurichna.com.
Independence Holding Company Unveils Technology Platform to Administer Full Spectrum of Health Products on Private and Public Exchanges
MyHealthGuide Source: IHC Health Solutions, Inc., 2/25/2015, www.thinkihc.com
Stamford, CT and Atlanta, GA -- Independence Holding Company announced that IHC Health Solutions, Inc., which administers multiple health insurance lines of business for IHC's carriers and other insurance companies, has launched EbixEnterprise, a state-of-the-art system in conjunction with Ebix, Inc.
IHC's successful launch of EbixEnterprise marks a multi-year project that started in 2012 when IHC and Ebix first partnered to develop the comprehensive platform. This system encompasses several Ebix products that connect multiple insurance constituents, including consumers, health providers, risk takers (carriers, issuers and health plans), distributors (marketers, producers and health exchanges) and administrators (payors and TPAs). EbixEnterprise integrates all of the following tools and services: customer relations management (CRM), insurance shopping, enrollment, fulfillment, billing/collecting, policy administration, claims payment, distribution compensation, document management, audit, workflow, and full accounting; as well as delivering enhanced reporting and business intelligence through web portals, self-service capabilities and a data warehouse.
Pete Wirski, president of IHC Health Solutions, stated, "Given IHC's strong background in administering individual and group major medical products for numerous carriers, this new, fully-integrated platform further enhances our capabilities to manage a diverse portfolio of health insurance products in multiple health care markets on both public and private exchanges. We are considered to be a market leader nationally in providing front and back-end systems to health systems, insurance companies and ACOs."
Jim Senge, senior vice president of Ebix Health, commented, "The EbixEnterprise technology platform addresses the emerging health insurance market needs in the post health care reform industry. This platform seamlessly integrates Ebix's new and multiple existing products for a full spectrum of both front-end and back-end health insurance sales and administration needs. Unlike many technology solutions that exist today, EbixEnteprise is a turn-key solution for carriers/issuers, health plans, ACOs, health delivery networks and other entities participating in the new health care markets."
For more information on IHC's launch of EbixExchange, please contact Pete Wirski at 602-417-2169.
About Independence Holding Company
Independence Holding Company is a holding company principally engaged in the life and health insurance business, and the acquisition of blocks of policies, through its insurance company subsidiaries (Standard Security Life Insurance Company of New York, Madison National Life Insurance Company, Inc. and Independence American Insurance Company) and its marketing and administrative affiliates. Standard Security Life furnishes medical stop-loss, group major and limited medical, short-term medical, group long-term and short-term disability and life, group and individual dental, vision and various supplemental products. Madison National Life sells group life and disability, group major and limited medical, group and individual dental, individual life insurance and various supplemental products. Independence American offers pet insurance, non-subscriber occupational accident, short-term medical, medical stop-loss, group and individual dental and various supplemental products. IHC owns certain subsidiaries through its majority ownership of American Independence Corp. (NASDAQ: AMIC), which is a holding company principally engaged in the insurance and reinsurance business. Visit www.ihcgroup.com.
About IHC Health Solutions, Inc.
IHC Health Solutions is a full service administrative services company that operates in the individual and small employer markets and is licensed to do business in most states. For a complete list of states where the company is licensed, please contact us. The company administers a variety of IHC products and provides services across multiple carriers and distribution channels. Visit www.thinkihc.com.
About Ebix, Inc.
A leading international supplier of On-Demand software and E-commerce services to the insurance, financial and healthcare industries, Ebix, Inc., (NASDAQ: EBIX) provides end-to-end solutions ranging from infrastructure exchanges, carrier systems, agency systems and risk compliance solutions to custom software development for all entities involved in the insurance industry.
With 40+ offices across Australia, Brazil, Canada, India, New Zealand, Singapore, the US and the UK, Ebix powers multiple exchanges across the world in the field of life, annuity, health and property & casualty insurance while conducting in excess of $100 billion in insurance premiums on its platforms. Through its various SaaS-based software platforms, Ebix employs hundreds of insurance and technology professionals to provide products, support and consultancy to thousands of customers on six continents. Visit www.ebix.com.
US HealthCenter's PredictiMed™ Receives Validation from the Intel-GE Care Innovations Validation Institute
MyHealthGuide Source: US HealthCenter/PredictiMed, 2/10/2015, www.USHealthCenterInc.com
ROSEVILLE, CA -- On behalf of Intel-GE Care Innovations™ and the Validation Institute, US HealthCenter d.b.a. PredictiMed™, and its PredictiMed™ Predictive Modeling Analytics Engine has been validated and issued a stamp of approval. PredictiMed™ is now part of Intel- GE Care Innovations™ Validation Institute's Trusted Community. Through validation, PredictiMed™ has achieved a highest standing in the healthcare industry and has been validated to adhere to the highest standards of validity.
The PredictiMed™ guarantee exemplifies valid metric measurement that is focusing only on the diagnosis codes that the Agency for Health Research and Quality says can be addressed. It is measuring events across the population (thus avoiding participant bias, a common and well-understood invalidator), and emphasizes ER and inpatient event avoidance. PredictiMed™ incorporates secular event rate trend into the event rate tally to avoid taking credit for reductions (such as in heart events) that would have, statistically speaking, taken place anyway. Furthermore, PredictiMed™ is willing to guarantee a reduction of ER events and hospitalizations by 25%, depending on participation and compliance of a population.
"Our focus has been the identification and health management of individuals in the pre-disease/pre-symptomatic state through our PredictiMed™ analytics platform to get ahead of the later stage illness curve that drives higher costs and poor outcomes. Our results prove that by applying our evidence based guidelines approach to these, as well as individuals with known conditions, we can reduce costs and improve outcomes. We are proud to have our years of work validated by the CI Validation Institute and look forward to continuously being measured by the highest standards," said Dr. Raymond Gavery, Chairman and Chief Executive Officer of US HealthCenter/PredictiMed.
The Institute had the opportunity to validate PredictiMed's™ ability to identify and lower the predisease high risk level, which may precipitate a higher use of ER and hospital services, in thirteen major disease categories to a lower level where the preemptive intervention can be applied and thus reduce the incidence of ER visits and hospitalizations between 80 and 93%, depending on the disease category. Lower back pain outcome was the only disease category which resulted in 17% reduction from the critical risk level to a lower, less emergent level.
US HealthCenter provides services to employers, health plans, health systems, Third Party Administrators, Coalitions and Government institutions, and will be soon entering the Accountable Care Organizations and Exchanges. With clients in all 50 states, the Company's on-going mission is the improvement of health outcomes, reduction of chronic disease incidence, as well as direct and indirect healthcare costs. US HealthCenter's PredictiMed™ new generation Predictive Modeling Analytics Engine and an early preventive and preemptive intervention was evaluated by the CI Validation Institute and validated as to its predictive accuracy and presymptomatic intervention and its ability to provide primary guarantee of positive outcomes to its clients.
"Our vision is that the Intel-GE Care Innovations Validation Institute will raise the bar on the efforts made to demonstrate the quality and effectiveness of remote care management and population health solutions," said Karissa Price, Executive Director of the CI Validation Institute. "Through the Validation Institute, Care Innovations seeks to provide organizations with unbiased, third-party evaluation to ensure its assessment methodology is sound, which is critical in building population health programs that will help those who are sick better manage their health and prevent those who are at-risk from developing costly chronic conditions."
"Our team is honored to receive this recognition from the CI Validation Institute. We have a strong sense of purpose to not only improve the quality of life of our members, but to demonstrate our commitment to the scientific validation of our platform," said Gavin Quinnies, President and Chief Operating Officer of US HealthCenter/PredictiMed.
About the Intel-GE Care Innovations Validation Institute
The CI Validation Institute's goal is to help organizations involved in population health – from Health Plans to Employers to Vendors – adhere to the highest standards of validity, allowing them to compete on the basis of integrity and performance rather than hyperbole. The Validation Institute will impartially challenge the status quo of typical population health outcomes measurement, with the objective of impacting how the industry establishes its credibility. Visit www.validationinstitute.com.
PredictiMed™ is a Software as a Service (SaaS) based personalized, predictive medicine analytics and population health management business, located in Milwaukee, WI. The Company's history and on-going mission is the improvement of health outcomes and the reduction of direct and indirect health costs. The Company's portfolio of proprietary data analytic tools, products and services are marketed under the brand name of "PredictiMed".
The Company has developed its proprietary predictive software platform integrating big data and cloud computing into a (SaaS) model to assist employers, consumers, health plans, providers and insurers in the identification and management of pre-disease, disease and end stage disease states and associated medical costs across the entire continuum of care. The Company's business intelligence solution utilizes integrated data to identify health risks, treatment gaps and inefficiencies and applies practical, clinically validated solutions to the medical management process in order to improve quality and lower costs. Contact Gavin Quinnies, President & COO, at 262.853.2572, gquinnies@USHealthCenterInc.com and visit www.USHealthCenterInc.com.
Aetna Offers On-site
Clinic For Headquarter Employees
Aetna's on-site pharmacy
Often, the doctors and nurses at companies' on-site clinics are
staffed by third-party vendors. Ethan Slavin, a spokesperson for
Aetna, said this creates a separation between workers and their
employers when it comes to sensitive information.
DialysisPPO Announces '2015 New Year Industry Update' Newsletter
MyHealthGuide Source: DialysisPPO, 2/26/2015, www.dialysisppo.com
King of Prussia, PA - DialysisPPO announces the issue of their 2015 new year Industry Update newsletter.
"2015 is shaping up to be a watershed period for the dialysis industry, as the major players are expanding their services into the primary care and hospital arenas in anticipation of Accountable Care Organization (ACO) and capitation business models. The transition to this brave new world will take years, and self-funded plan sponsors will continue to be negatively impacted by ever-escalating fee for service pricing." Said Mike Jeffers, VP of Sales and Marketing.
Visit our newsletter at http://dialysisppo.com/Newsletter/2015-February.html .
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. Contact Mike Jeffers, VP of Sales and Marketing, at 610-590-2203 and visit www.dialysisppo.com.
Navitus Health Solutions Announces Southwest Expansion
MyHealthGuide Source: Navitus Health Solutions, LLC 2/25/2015, www.navitus.com
MADISON, WI -- Navitus Health Solutions, LLC, announced it will open a new regional office in Phoenix, Arizona, to accommodate its tremendous corporate growth. The new 22,000 square-foot regional office located at High Street in the Northeast Valley of Phoenix at Loop 101 and 56th Street is expected to bring an estimated 70 new jobs to the area. Navitus anticipates moving into the space in spring 2015.
Navitus, a national, full pass-through pharmacy benefit manager (PBM) headquartered in Madison, Wisconsin, also has campuses in Appleton, Wisconsin, and Austin, Texas, and a specialty pharmacy, Lumicera Health Services, LLC.
"We have experienced significant growth in the Western U.S. and are excited about our Southwest expansion," said Terry Seligman, President and CEO of Navitus. "Consistent with our business model of complete transparency, this space will evoke the same open and welcoming aesthetic as our other campuses and offer a great workspace to PBM professionals in the Phoenix area."
Navitus is unique in the PBM industry with its transparent offering of a full-pass through of all pharmacy network discounts and manufacturer rebates. In addition, Navitus allows clients to audit all of their contracts to ensure they are receiving the full discount they've been promised. This unique position in the PBM industry is a strong draw for clients and employees alike.
Navitus Health Solutions, LLC, a division of SSM Health, is a full-service, URAC-accredited pharmacy benefit management company. As a zero-spread, full pass through pharmacy benefit manager (PBM), Navitus aligns performance with plan sponsors' benefit goals to deliver comprehensive clinical programs and cost-saving strategies that lower drug trend and promote good member health. Navitus provides its flexible services to government entities, self-funded employers, coalitions, labor organizations, third-party administrators, and health plans, including managed Medicaid, Exchanges, and Medicare Part D. Call 877-571-7500 and visit www.navitus.com .
International Conference Scheduled for
April 13-15 in Panama
The conference will be held at the brand new upscale Hilton Panama,
situated on Panama Bay near the main business district, and is
within walking distance to many of the city's finest restaurants and
cafés. It is also just 20 minutes from Tocumen International
Airport. The SIIA room block at the Hilton Panama will end on March
23, 2015, so if you would like to stay at the host hotel, please
register and make your room reservations at your earliest
opportunity as we expect the hotel to be sold out.
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.
Fairmont Specialty Announces the Promotion of Lauren Woods and Jim Haggerty
MyHealthGuide Source: Fairmont Specialty, 2/26/2015, www.FairmontSpecialty.com
Eatontown, NJ -- The Accident & Health division of Fairmont Specialty, part of the Crum & Forster Enterprise, is pleased to announce the promotion of Lauren Woods to Vice President of Marketing and the promotion of Jim Haggerty to Vice President of Medical Programs.
Since 2007, Lauren has been an integral part of the Fairmont Specialty marketing team. Lauren is involved in strategic planning, heavily networks within the industry and has been forming relationships with other Fairfax companies. She has significantly contributed to the growth of the portfolio via new business and assisting with retaining large programs. Over the past year Lauren has also been an integral part of expanding our presence internationally. Lauren will continue to pursue new growth opportunities along with increasing Fairmont Specialty's brand awareness and adding to the positive reputation of our company.
Jim has been with Fairmont Specialty's Accident & Health since 2007. Over the past eight years, Jim has demonstrated his leadership and senior executive skills, while profitably growing his portfolio. This promotion is in recognition of Jim's continued success in managing Fairmont Specialty's medical programs portfolio, contributing to the strategic management of the division, and overall contributions to the success of the division. Jim will continue to expand the medical portfolio and provide the excellent program management and customer service our clients have come to expect.
"Lauren and Jim have worked extremely hard to reach this achievement. I am personally excited about this development and look forward to our division's continued success!" said Gary McGeddy, Executive Vice President.
About Fairmont Specialty, part of the Crum & Forster Enterprise
Fairmont Specialty is a member of the Crum & Forster Enterprise, a national commercial property and casualty group of insurance companies wholly owned by Fairfax Financial Holdings, rated A (Excellent) by A.M. Best. Fairmont offers a unique variety of Accident & Health insurance and reinsurance products, including Stop Loss, Transplant, Managed Care Excess, Fixed Indemnity, Dental, AD&D, Occupational Accident, Blanket Special Risk, College Sports, K-12, Travel, Inbound/Outbound and Pet Insurance. Fairmont also offers a broad range of international product capabilities through its Fairfax counterparts in over 60 countries, in addition to being a coverholder for Advent, a Lloyd's of London Syndicate. Fairmont Specialty is dedicated to providing alternative solutions in an ever changing accident and health insurance market. Contact Lauren Woods, Vice President of Marketing, at firstname.lastname@example.org, 732-676-9833, and visit www.FairmontSpecialty.com.
Imagine Health Names Chris Cigarran as President
MyHealthGuide Source: Imagine Health, 2/24/2015, www.imaginehealth.com
COTTONWOOD HEIGHTS, UT -- Imagine Health, the nation's leading independent creator of top-performing healthcare provider teams that typically save large employers more than 20 percent in healthcare benefit costs, announced that Christopher (Chris) T. Cigarran has joined the organization as its new president.
The highly respected and accomplished healthcare leader will use his proven experience across sales, finance, operations and human resource (HR) management to help the company grow its SmartCare teams in existing markets while helping the company expand into new markets.
"I chose to join Imagine Health because of what Allison Robbins and the team at Imagine Health have created," Cigarran said. "They have built and deployed a timely and innovative business model that is uniquely positioned to transform both the quality and cost of healthcare in a dramatic way. The measurable positive impact that Imagine Health has on employers, providers, and individuals made my choice to join the Imagine team an easy one. I am thrilled to help navigate the company through what I anticipate will be a period of explosive growth as more employers take advantage of what we offer."
Cigarran brings a wealth of relevant experience to Imagine Health, including 13 years in various leadership roles at Nashville, TN-based Healthways, the nation's leading provider of disease management and well-being services. Most recently he served four years as president of the employer and government division. Before taking on this role, he spent five years as the company's chief human resources officer, where he built a team responsible for the people, processes and HR strategy required to support the rapid growth of a public company. In this role he helped the organization win several national awards including being included on Fortune's Best Places to Work list as well as multiple recognitions from the National Business Group on Health.
Cigarran also spent several years as a consultant working with multiple large U.S. and Canadian companies.
"We are excited to add a healthcare executive of Chris' caliber to our already strong team," said Allison Robbins, founder, chairman and CEO of Imagine Health. "His leadership experience and background in developing a high-performing company culture will be invaluable in keeping us on track and true to our core values as we grow. We welcome Chris and look forward to an exciting and successful future with his leadership."
Imagine Health leverages sophisticated data analytics and the purchasing power of its large-employer clients to negotiate discounted reimbursement rates with top-performing providers in exchange for incremental volume. The quality and efficiency improvements from the selected top-tier providers typically exceed 20 percent.
The company recently closed $21 million in Series A funding, its first outside funding, which it plans to use to expand its transformative approach to healthcare delivery into new markets, including immediate development activities in Phoenix, San Francisco and Atlanta. Imagine Health currently has high-performance networks-known as SmartCare-in Chicago, Dallas, Houston, San Antonio, Albuquerque and Boise comprising more than 22,000 healthcare providers and 350,000 members.
About Imagine Health
Since 2009, Imagine Health has been transforming healthcare by matching employers that have large concentrations of employees in a single geographic area with custom-built teams of the highest-performing providers. This approach, which the company calls SmartCare, is enabling Fortune 100 and other large organizations to save 20 percent or more on the cost of providing health benefits to their employees while ensuring more personalized service that delivers better care and outcomes. Employers can select from one of Imagine Health's existing provider teams or have one custom-built. SmartCare is currently available in Chicago, Dallas, Houston, San Antonio, Albuquerque and Boise, with plans to expand nationwide. Contact Scott Robinson at email@example.com and visit www.imaginehealth.com.
New Free Website, Guroo, Reveals what Healthcare Providers are Paid -
Price Transparency Debated
MyHealthGuide Source: Melanie Evans, 2/25/2015, Modern Healthcare Article
Healthcare consumers have a new tool to compare prices using data from some of the largest U.S. health insurers, but comparison shopping will remain a challenge for most. The Health Care Cost Institute, a not-for-profit healthcare research organization, launched the first of two websites conceived to help consumers navigate prices for medical services.
The website, Guroo, allows consumers to search for average prices for 70 services across more than 300 hundred cities, 41 states, coastal California and the District of Columbia.
Prices are drawn from medical claims for 40 million Americans covered by Aetna, Assurant Health, Humana and UnitedHealthcare.
Consumers will be able to identify the low, average and high prices within each market, and they will see prices for all of the services to treat certain conditions, including office visits, laboratory and diagnostic tests, and other services in addition to the procedures themselves.
"HCCI is going to use this data to ultimately create a national source of truth for consumers," said Tom Beauregard, executive vice president of UnitedHealth Group.
The new website comes amid a wave of healthcare price transparency tools developed by entrepreneurs, health insurers and states to give patients and employers more ability to shop around. Pricing tool Castlight Health went public roughly one year ago with a hugely successful initial public offering. (Wall Street has lost some of its enthusiasm recently, although the company has been adding customers and narrowing its losses.) A dozen states operate all-payer claims databases. Regulators, too, may use price data to challenge hospitals and doctors to justify wide differences in price.
Price Transparency Debated
But useful price information for consumers and regulators remains out of reach in many areas of the country. "There's still a big distance between what you experience as an individual and the price you might have to pay and what ends up being disclosed," said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute. State data is often difficult for consumers to access and understand.
For the new website, the Health Care Cost Institute selected conditions for which patients can plan ahead. "We focused on shoppable, discretionary, scheduled services," said David Newman, HCCI executive director.
The prices do not yet include the cost of pharmaceuticals, and the website does not include data on quality, but officials said measures of quality are under development.
Average prices will give consumers a reference point to help them compare prices as they shop. Guroo prices are accurate "assuming that the patient, on average, is average," he said.
But that is rarely the case, de Brantes said. That's because illness and medical care are highly complex. To better prepare patients for differences and sticker shock, public pricing should clearly disclose what services are included -- and excluded -- from estimated medical bills.
"Let's be clear about what's in and what's out and how that might affect the price I have to pay for that particular condition, illness or injury," de Brantes said. "Healthcare is complex and people aren't stupid. Explain what you're doing. Be clear about it."
Patients who will benefit most from public prices are those who remain uninsured despite the Affordable Care Act's expansion of subsidized health plans or those with extremely high deductibles who face significant expenses for everything but the most routine preventive care.
Some experts also suggest that price transparency can help slow healthcare inflation and the overall cost of healthcare, though price growth has recently been weak.
Mark Pauly, a health policy and management professor at the University of Pennsylvania, said comparison shopping among such a small percentage of the nation's patients will do little to slow the overall growth in U.S. healthcare.
But employers and regulators can use published prices to exert pressure on providers to lower or justify their rates, as has been the case in Massachusetts and New Hampshire, said Chapin White, an economist and senior policy researcher for RAND Corp. who studies price transparency.
Later this year, patients with health plans from insurers involved in the effort will have access to a separate website developed by the Health Care Cost Institute that will provide personal information on consumers' out-of-pocket costs.
Beware of Stop-Loss Coverage Gaps When Choosing a Self-Funded Major Medical Plan
MyHealthGuide Source: Alden J. Bianchi, Esq. and Edward A. Lenz, Esq., 2/24/2015, Mintz Levin Employment Matters - Full Text
Excerpts (Click above link for full text):
From the Authors: This paper focuses on self-funded plans that involve employer exposure to catastrophic liability under major medical plans that cover inpatient hospital and physician services. Self-funded MEC plans that cover only preventive and wellness services do not expose employers to such liability and therefore are not the subject of this paper. Nor are self-funded "minimum value lite" plans that do not cover inpatient hospital or physician services. Note also that the paper focuses on the potential claims risks associated with gaps in stop-loss coverage. It does not address the federal regulations and reporting rules applicable to self-funded plans.
Several national and regional suppliers have developed self-funded arrangements consisting of administrative services, provider networks, and stop-loss coverage to protect against unusually large claims. Many of these arrangements are well constructed, and many of these suppliers are highly regarded.
But there is often a significant lack of coordination between the general coverage terms of the underlying self-funded group health insurance plans (which are subject to the ACA's insurance market and other reforms) and the terms of the accompanying stop-loss coverage (which is not considered health insurance and therefore is not subject to the ACA). This gap in coverage could result in major unanticipated claims liability for the unwary firm that adopts a self-funded arrangement.
These are examples of terms that ASA members have encountered in stop-loss policies. Some of these provisions are inconsistent with the ACA and other laws that apply to health insurance plans. Employers firms should carefully review their stop-loss policies to determine whether they include one or more of these provisions, many of which could materially increase the employer's claims risk.
Employers should discuss with their insurance representatives whether and to what extent such provisions can be deleted or modified to reduce the employer's exposure -- and what effect such changes would have on the cost of stop-loss coverage.
Actively at Work Provisions
Some stop-loss policies specifically exclude claims incurred by individuals who were not "actively at work" at the start of the stop-loss policy period -- for example, if the employee was already in the hospital on the policy's effective date. Federal and state regulations generally prohibit actively at work provisions from being used to delay or deny eligibility under health insurance plans, but those prohibitions generally do not apply to the stop-loss coverage. Thus, an individual who is absent from work may qualify as a participant in a self-funded group health plan but not be covered under the stop-loss policy. In such cases, the plan sponsor (i.e., the employer) would be liable to pay the claim.
Stop-loss policy terms labeled as, or referring to, "maximum reimbursements" are effectively lifetime or annual limits for aggregate -- but normally not for specific -- coverage, which cannot be imposed under the ACA. Similar terms include "specific excess loss benefit," "lifetime limit of liability" and "lifetime maximum." In each instance, once the limit is reached, the plan sponsor is liable. Lifetime limits rarely include "expenses incurred or paid in all prior periods." Thus, in the case of a chronic condition (e.g., cancer or AIDS) the plan sponsor's exposure may be amplified. Of course, an employer can change stop-loss carriers when the policy is up for renewal to one without such a feature and start the accumulation process anew.
Experimental or Investigational Claims
A stop-loss policy may decline to cover payments for treatment or services that are considered "experimental or investigational." The ACA generally requires group health plans to cover those services but only when they are part of a qualified clinical trial and the plan would cover that type of treatment if it were not experimental or investigational (e.g., prescription drug or radiation treatment).
Mental and Nervous Disorders
A stop-loss policy may carve out coverage for the treatment of "any illness or injury resulting from mental and nervous disorders or alcohol or drug abuse." But federal law (i.e., the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008) generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical and surgical benefits. As noted before, however, insurers in the 50-employees-and-over-market, and all sizes of self-funded plans, are not required to offer MH/SUD coverage.
Charges in Excess of ‘Usual and Customary'
Most health insurance plans take advantage of preferred provider only (PPO) networks where provider claims are subject to payment based on an agreed schedule. Stop-loss carriers will treat those payments as payable under the stop-loss contract. Outside of claims through a PPO, most plans limit claims payments or reimbursement to "usual and customary charges" (UCR). This describes the amount an insurance carrier or TPA decides to use as the starting point in the payment for a service. UCR is most often defined to mean the "amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service." In each case, it is important to ensure that the health insurance plan's definition agrees with the stop-loss policy. This takes on added significance in the case of out-of-network services. But even with in-network services, there is no assurance that the stop-loss carrier will agree to the negotiated rate.
Midyear Changes in Premium Rates and Underwriting Factors
Most stop-loss carriers reserve the right to change premiums or stop-loss calculation factors if the participation rate goes above or below the number upon which the original premium and stop-loss factors were set. The difference in census that most often invokes such a change is a monthly variation in enrollment of 10%. Such provisions are obviously designed to mitigate the stop-loss carrier's risk, not that of the employer. Of course, there are instances -- such as a merger, acquisition, or other corporate restructuring -- in which a midyear change is justified.
Right to Terminate
Stop-loss policies universally include early termination rights -- e.g., for nonpayment of premiums. Many stop-loss insurers also reserve the right to terminate based on inadequate participation, which is often a sign of adverse selection that can negatively affect the economics of the arrangement. The ACA bars insurance carriers and health insurance plan issuers from imposing minimum participation requirements on initial issuance of a group health plan. Such requirements may, however, be applied on renewal in the small-group fully insured market (fewer than 50 employee lives) other than during the annual open enrollment period from Nov. 15 to Dec. 15 of each year. The ACA does not prohibit a self-funded plan from requiring a minimum participation level.
Right of Rescission
"Rescission" in the group health plan context means the retroactive cancellation of a health insurance policy. Before the ACA took effect, insurance companies would sometimes retroactively cancel a policy in its entirety if the policyholder made a mistake on his or her initial application. While this was largely a problem in the individual market, the ACA prohibits rescission in both group and individual markets and by self-funded plans -- except in cases of fraud or intentional misrepresentation of material fact. But the ACA prohibition does not apply to stop-loss insurers, and many stop-loss policies allow rescission based on any mistake or misrepresentation, even if unintentional, and even if the mistake involved only one employee or an employee's dependent. Some carriers do not retain the right to rescind the entire policy but may reserve the right to offer adjustments to the premium or other terms of the policy if there has been a misrepresentation of material fact by the employer or an employee as a part of the underwriting or claim process. Because rescission materially increases risk, employers should be aware of rescission provisions and their potential effect on the solvency of a self funded health insurance plan.
The cost of a self-funded arrangement is not always apparent from the stop-loss policy itself. Stop-loss premiums are only a part of the story. The real cost also includes TPA fees and related costs, monthly claim fund contributions (the employer's portion of the claims payment), and, when appropriate, repayment of stop-loss "advance funding." Employers must understand all of the components of the fees being charged.
Choice of Law and Venue Restrictions
Stop-loss insurance policies often include provisions -- for example, specifying where lawsuits can be brought against the insurer, limiting when such suits can be filed, and subrogation provisions -- that conflict with state law. Other provisions can leave the plan sponsor exposed even in the case of a valid claim. For example, they may impose a shorter period for submission of claims than the plan allows.
Employers considering self-funded insurance should be aware of all of the provisions discussed in this paper. They should pay particular attention to certain specific provisions and try to negotiate changes to these terms to reduce the costs and risk that the employer will face: whether the stop-loss policy imposes annual dollar limits; whether claims will be denied if submitted outside a narrow time window; whether the policy excludes claims for certain services such as prescription drugs or mental health care; whether the policy includes rescission provisions; whether the policy includes rate increase triggers; and whether the policy imposes charges or fees in addition to the stop-loss premium.
Ideally, employers choosing self-funded insurance should be able to purchase stop-loss coverage that conforms to the ACA. In most cases, however, this is an unrealistic expectation. But efforts should be made to avoid the more egregious problems described in this paper, even if the cost of the stop-loss coverage increases as a result. At the very least, employers should be aware that self-funding with stop-loss coverage can potentially result in significant risks that must be carefully assessed and, to the extent possible, avoided or mitigated.
New Mexico Now
Requires Stop Loss Carriers to Comply with MLR
In his Risk
Manager Weblog, Bill Rustenburg, asks, ""Stop loss carriers are likely to exit the New Mexico market this
year leaving self-insured medical plans without coverage."
Case: Raible v. Union Security Insurance Co., 2015 WL 746213 (W.D. Pa. February 20, 2015) Court's Ruling
You already know that employee benefit plans established by
governmental entities are exempt from ERISA.
This issue is highlighted in the above Raible case. The
court applies very
broad definition of "a plan established by government" to conclude
government exemption from ERISA applies.
Raible was employed as a school nurse in a school district, a
government entity in Pennsylvania. Plaintiff also was a member of
the Pennsylvania School Board Association (PSBA). PSBA is not a
governmental entity. It provided disability benefits, insured by
Union Security Insurance Company, to its members.
Is this government employee's disability benefit governed by ERISA? The court concluded,
The court holds that this plan was "established" by the government because: (a) the school district purchased the plan for the exclusive benefit of its employees through the PSBA Insurance Trust; and (b) The school district is listed as a "participating employer" under the policy. Op. at 6.
Drinking Coffee Associated with 1/3 Less Risk of Multiple Sclerosis
MyHealthGuide Source: American Academy of Neurology via HealthDay
News, Washington, D.C, 2/26/2015,
Researchers stressed that the findings do not prove that coffee
fights MS -- a disease in which the immune system mistakenly attacks
the protective sheath around nerve fibers in the brain and spine.
Symptoms can include muscle weakness, numbness, vision problems and
difficulty with balance and coordination.
Researchers adjusted for other facors such as age, smoking habits, and sun exposure. (Higher vitamin D levels have been linked to a lower risk of developing MS, and less severe symptoms.) But the researchers could not account for all the possible differences between coffee lovers and non-drinkers.
According to the National Multiple Sclerosis Society, at least 2.3 million people worldwide have MS. It is more common in women than men, and typically strikes between 20 and 50 years of age.
Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 2/21/2015)
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.
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.
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:
Reader response and correction is encouraged. Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com.
The Value of Self-Funding
MyHealthGuide Source: The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, www.SIEFOnline.orgClick The Value of Self-Funding for overview, reasons, tools and examples 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 www.SIEFOnline.org.
March 18-20, 2015
• Evolving regulatory environment for self-insured health plans in
Panama City, Panama. Call
800/851-7789 and visit www.SIIA.org
May 6-8, 2015
July 15-17, 2015
July 21-23, 2015
February 9-11, 2016
March 30-April 1, 2016
July 13-15, 2016
October 17-19, 2016
February 8-10, 2017
March 15-17, 2017
September 13-15, 2017