MyHealthGuide Newsletter
News for the Self-Funded Community
5/2/2016

Published weekly by MyHealthGuide, LLC (www.MyHealthGuide.com). This Newsletter is for personal, non-commercial use only.  This weekly newsletter is FREE OF CHARGE to subscribers.  Subscribe free. Send news, press releases and announcements to mailto:Info@MyHealthGuide.comClick here if Newsletter stops arriving.

TABLE OF CONTENTS

General & Company News

People News

Job News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures


General & Company News


Southern Scripts, LLC has been acquired by Employers Health Network Holdings, LLC

MyHealthGuide Source: Chaffe Securities, Inc, 4/29/2016, Chaffe Announcement

Chaffe Securities, Inc, a wholly owned subsidiary of Chaffe & Associates, Inc. (together "Chaffe") is pleased to announce that it acted as the exclusive financial advisor to Southern Scripts, LLC ("Southern Scripts") in its sale to Employers Health Network Holdings, LLC ("EHN").

Southern Scripts is the only pharmacy benefits management (PBM) company headquartered in Louisiana. Southern Scripts focuses on combining pass-through pricing and novel drug utilization management techniques to achieve significant savings on pharmacy benefits for its clients. Southern Scripts' pharmacy networks consist of over 60,000 pharmacies nationwide.

EHN is a national provider of custom healthcare vendor networks to business coalitions and self-funded employers. Southern Scripts' owners, LeAnn Boyd and Steven Boyd, have joined the EHN team and will continue in their roles as Southern Scripts' CEO and Executive Vice President of Sales & Business Development, respectively.

Dr. LeAnn Boyd said: "For us, selling or merging our company was more than just a business transaction--it was about finding the right partner for long-term growth and success. EHN is a like-minded partner and shares our goal of creating simplified and straightforward healthcare for self-funded employer groups. Chaffe clearly understood our goals and was essential not only to navigating the process of the business deal, but also evaluating the structure and operations of the organization post-merger."

With Southern Scripts' focus on providing transparent pharmacy benefit management services, EHN enhances its ability to offer greater options for self-funded health plans. Together with Southern Scripts, EHN can now provide a more fully integrated healthcare network solution to clients nationwide.

About Chaffe & Associates, Inc,

Chaffe & Associates, Inc, is an investment banking firm headquartered in New Orleans. Chaffe provides merger & acquisition services, valuations, and other strategic advisory services to clients ranging from family owned businesses to publicly held corporations spanning a wide range of industries.

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HCAA Announces New Format for 2016 TPA Summit

MyHealthGuide Source: Health Care Administrators Association (HCAA) , 4/25/2016, www.HCAA.org

MINNEAPOLIS, MN -- The Health Care Administrators Association (HCAA), a leader in advocacy, education and networking for the self-funding industry,  announces its new conference format and the debut of its 2016 TPA Summit. The two-and-a-half-day event will be held July 13-15, 2016 in Dallas, Texas, headlined by opening keynote Mike Ferguson, president and CEO of the Self-Insurance Institute of America (SIIA) and general keynote Connie Podesta of Connie Podesta Presents, LLC.

In addition to the keynotes and all-inclusive general sessions, HCAA has introduced an industry-shaping change: TPA Summit will now offer three unique and dedicated paths for success: Operations, Leadership and Marketing/Sales. Unlike many conferences with "tracks" that require an attendee to commit to just one track, HCAA's TPA Summit is offering several paths to follow and the ability for the attendee to choose the parts of each path offered that best suit their unique needs and interests.

  • The Operations Path provides a robust examination into the factors and best practices needed to achieve operational excellence - essential to succeeding in today's competitive marketplace.
  • The Leadership Path presents a better understand methods to develop and enrich human capital.  The path discusses how to inspire millennials and will hear industry visionaries both share their formulas for success, as well as their predictions for the future.
  • The Marketing/Sales Path is dedicated to exploring inventive new tools and products, understanding how to use existing tools and products more effectively, and examining ways to reshape corporate branding to set their organizations apart from the competition.

"HCAA has always provided an advanced look and shared guidance into what TPAs need to accomplish in order to remain successful - now, and well into the future," said Steve Rasnick, vice president of HCAA. "This year's new TPA Summit brings an invigorating excitement to the table and will be unlike any of our past operational conferences. TPA Summit examines the core competencies of operations, leadership and marketing/sales in fresh ways and provides truly actionable guidance to help TPAs become more flexible, opportunistic through seamlessly integrated and diverse offerings."

  • Mike Ferguson will present the opening keynote session on Wednesday, July 13 from 1:45-3:15 p.m. on "Positioning the Self-Insurance Industry as a More Effective Advocacy Force." This session will highlight current initiatives in the areas of media outreach, shaping the political landscape, lobbying, litigation and grassroots mobilization designed to position the self-insurance industry as a more effective advocacy force at both the federal and state levels. Updates will also be provided on timely legislative, regulatory and litigation developments affecting TPAs and other companies involved in the self-insurance marketplace.
  • Connie Podesta will present on Thursday, July 14 from 8:45-10:15 a.m. a keynote session titled, "Lead Like You Mean It!" She says that successful people are great influencers. They know how to get consensus, ownership and buy-in from the people who count-without manipulation, intimidation, sacrificing relationships, or stepping on toes. She discusses that getting the job done the right way hinges on your ability to "sell" yourself, your products, your services, and your ideas in such a trusting and positive way that people will choose to: follow your lead, cooperate with you, learn from you, buy from you, partner with you, and support you - so you can get the job done right!

Click here for more information on the 2016 TPA Summit and the full schedule of sessions.  Discount registration is available through May 19, 2016.

About HCAA

The Health Care Administrators Association is the nation's most prominent nonprofit trade association that supports the education, networking, resource and advocacy needs of third-party administrators (TPAs), insurance carriers, managing general underwriters, audit firms, medical managers, technology organizations, pharmacy benefit managers, brokers/agents, human resource managers and health care consultants. For nearly 35 years, HCAA has taken a leadership role in legislative advocacy, working to increase its influence with policymakers and other stakeholders in order to transform the self-funding industry and expand its role within health care.  Visit www.hcaa.org and connect with us at @HCAAinfo, HCAA LinkedIn or HCAA YouTube.

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Group Resources® Celebrates 35th Anniversary

MyHealthGuide Source: Group Resources®,  4/1/2016, www.GroupResources.com

April 1, 2016 marks the 35th anniversary of Group Resources.

"I want to thank our Stop Loss Carriers, Vendor Partners, Clients, Brokers, Consultants and our dedicated employees for supporting Group Resources for the past 35 years. Without your friendship, support and loyalty this milestone could not have been achieved", says Tom Byrd, RHU President & CEO.

About Group Resources, Incorporated

For thirty-five years, Group Resources has led the way to healthier employee and healthier businesses for their clients. On the cutting edge of new trends in healthcare risk management, Group Resources combines modern technology and old-fashioned customer service to administer health and welfare plans. Based in Duluth, GA, Group Resources also has locations in Baton Rouge, LA, Chicago, IL, Dallas, TX, Detroit, MI, Nashville, TN, Phoenix, AZ and Sioux City, IA.

To learn more about Group Resources and how we can help your business or institution achieve cost-effective benefit plans both you and your employees can feel good about, contact Robby Kerr, EVP and CMO, at Robby@GroupResources.com, 678.475.3607 and visit www.groupresources.com.

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New World Medical Network Announces Agreement to Provide Significant Medical Savings Through "One Price Healthcare" Platform to Municipality in Botetourt County, Virginia

MyHealthGuide Source: PRWeb, 4/19/2016

NEW YORK, NY -- New World Medical Network™ (New World) announces an agreement to provide its services to Botetourt County, Virginia with the roll-out of the all-inclusive One Price Healthcare® quality domestic medical tourism platform that will not only provide their employees significant savings on select procedures but also the assurance that the same transparent, reliable price for every procedure will be delivered.

"The leadership of Botetourt County has, like many municipalities, been searching for innovative ways to reduce their health costs without increasing deductibles and co-pays to the members. A strategy that includes transparent bundled pricing for elective medical services at prices less than the regional average can help save the County money and provide quality healthcare services to the members. When these savings are shared with employees, a major family budgeting need is also addressed; out-of-pocket costs. These savings are available for both employer and employee by using New World's network of quality services from providers located in Oklahoma, Georgia and New York. This new transparent, bundled price model for members who elect to travel for treatment marks a pivotal shift in the way healthcare is delivered in the United States. We are optimistic that our agreement will result in a win-win for both employer and employee," shared New World's COO, Terry Johnson.

"As administrative executives in today's governmental world, we have seen many of our costs rise, particularly as relates to health costs. Many factors have contributed to this issue, but we were surprised to learn of this new way to help reduce costs provided through New World Medical Network. We welcome the chance to both save money on health costs and to share these savings with our employees." said David Moorman, Deputy County Administrator.

About Botetourt County

On the edge of a modern metropolitan area, Botetourt is a dynamic and vibrant county of rich and unique carefully protected and preserved historical and natural resources. Visitors from around the world are drawn to its mountains, waterways, scenic highways, historic and cultural attractions, and award-winning sports competition and entertainment venues. Businesses from across the nation and around the globe have located to Botetourt and enjoy advantages of reliable and responsive governmental and community partners, an ample and skilled workforce, low costs, superior access, and an enviable quality of life. Call 540-928-2006 and visit www.BotetourtVA.gov.

About New World

New World Medical Tourism LLC (New World), is run by experienced healthcare and insurance professionals and caters to the self-insured marketplace - TPAs, companies, municipalities, and unions - with its one-cost, all-inclusive approach to non-emergent medical procedures and surgeries called "One Price Healthcare®." The New World Network consists of quality, accredited medical facilities within the United States as well as Costa Rica, often saving organizations roughly 30-50% off U.S. costs for select procedures. The platform attaches to an existing health plan, achieved with a simple amendment to the plan document; there is no need for Open Enrollment and the program can be implemented at any time. Contact Cathy Nenninger at cnenninger@newworldmedicalnetwork.com, 800-475-PATIENT (7284) and visit NewPatient.Net.

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Self-Insurance Political Action Committee (SIPAC) Discuss Self-Funding and Captives with Nebraska Senator Ben Sasse

MyHealthGuide Source: Self-Insurance Institute of America, 4/27/2016, www.SIIA.org

Washington, DC -- SIPAC is moving full steam ahead in supporting federal candidates that can make an impact for SIIA and its members, now and in the long-term.

Ben_Sasse
Senator Ben Sasse, (R) Nebraska

Yesterday, SIPAC co-hosted a breakfast discussion with freshman Senator Ben Sasse of Nebraska. Sen. Sasse won election in 2014 by travelling around Nebraska on a tour bus, visiting each of the state's 93 counties. Working with freshman Members of Congress is an important part of our activities: building early relationships and helping frame the importance of our policy issues among the myriad of other topics being discussed.

In addition to serving on the Joint Economic Committee, Sen. Sasse sits on the Senate Banking, Subcommittee on Insurance. Prior to his time in the Senate, he was appointed and confirmed as Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services. During that time, Sen. Sasse advised the Secretary on a broad spectrum of health policy issues.

At the breakfast, SIPAC was able to discuss self-insurance and captive issues for nearly an hour with the Senator, who has an excellent grasp of our issues. Specifically, he understands the importance of self-insurance in creating cost-effective coverage for both employers and employees. Discussion touched upon the importance of ensuring regulators not define stop-loss as health insurance and the significance of its availability within the market. Topics also included the need to clarify the recent legislative changes to 831(b) captives and the role captives play in risk mitigation.

About SIPAC

SIPAC continues to play a key role in building relationships with federal candidates through hosting and participating in events in D.C. and elsewhere.   SIPAC would like to thank each of our contributors for supporting our industry issues and the federal candidates who can make a difference. If you would like more information on future events, candidates, or SIPAC in general, please contact Wrenne Bartlett at wbartlett@siia.org and 800-851-7789.

About SIIA

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

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People News



Brentwood Services Administrators Inc. Promotes Matt Anglin to Senior Vice President of Claims

MyHealthGuide Source: Brentwood Services Administrators Inc. (BSA), 4/27/2016, www.bwood.com

BRENTWOOD, TN -- Brentwood Services Administrators Inc. (BSA), headquartered in Brentwood, Tenn., has promoted Matt Anglin, AIC, to the position of senior vice president of claims, according to Jeff Pettus, president and chief executive officer of Brentwood Services Administrators Inc.

Anglin will have an expanded role as senior vice president of claims, focusing on occupational accident and non-subscriber claims, Pettus indicates.

Previously serving as assistant vice president of claims, Anglin came to BSA in 1999 as a senior claim adjuster and worked his way up through the ranks to his current position overseeing BSA's accident and health programs.

Anglin began his claims career as a claims adjuster in Liberty Mutual in 1994. He was named claims manager at Johnston & Associates in 1995, where he helped establish a regional third-party administrator. In 1997 Anglin became a claims adjuster with WCASC and quickly became supervisor within one year.

Anglin holds a bachelor of arts in political science from the University of Tennessee, Knoxville. He holds the Associate in Claims (AIC) designation.

About Brentwood Services Inc.

Brentwood Services Inc. is an independent employee-owned company headquartered in Brentwood, Tenn., and specializing over the past 26 years in structuring and managing alternative market solutions for employers and insurance providers. 

About Brentwood Services Administrators Inc.

Brentwood Services Administrators Inc. provides claims management and loss control services to employers and employer associations with self-insured and large deductible programs for workers' compensation and other casualty lines throughout the contiguous 48 states. BSA's aggressive coordinated approach to claims administration and loss control has a proven track record of reducing the cost of claims for its clients. BSA also provides underwriting, policy management and accounting services to association-sponsored pools and mutual insurance companies.  Contact John Smitherman, senior vice president of sales, at (800) 524-0604, (615) 263-1300, bsiinfo@bwood.com and visit www.bwood.com.

About Brentwood Reinsurance Intermediaries Inc. (BRII)

Brentwood Reinsurance Intermediaries Inc. (BRII) provides insurance and reinsurance brokerage services encompassing self-insurance, guaranteed cost and deductible insurance with a focus on workers' compensation, excess liability lines, and accident and health reinsurance.

About CompPoint Managed Care Inc.

CompPoint Managed Care Inc., a managed care provider and wholly owned subsidiary of BSI, offers medical case management, utilization review, medical bill review, pharmacy benefits management and other ancillary services designed to control claim costs.

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Job News


International Medical Group Seeks Stop Loss Underwriter

MyHealthGuide Source:  International Medical Group, 4/19/2016, www.imglobal.com

International Medical Group - Stop Loss, headquartered in Indianapolis, is seeking an experienced Stop Loss Underwriter to join a unit that has been at the forefront of stop loss insurance for the past 25 years.

The Stop Loss Underwriter will underwrite new and renewal stop loss clients and work closely with producers to provide excellent service by meeting deadlines, providing accurate quotes, and providing timely correspondence.

This role reports directly to the VP of Underwriting. In addition to outside producers, this position requires interaction with stop loss marketing, administration, and claims. 

Duties and Responsibilities

  • Risk assessment and pricing of new business and renewals
  • Effective communication with producers and internal marketing staff
  • Develop and maintain strong relationships with outside producers
  • Adherence to company guidelines and polices.
  • Maintain a profitable block of business

Skills and Abilities

  • A minimum of 2 years stop loss underwriting experience
  • Strong risk analysis and mathematical skills
  • High level of accuracy
  • Ability to work with and assist others when needed
  • Ability to communicate effectively
  • Ability to use Excel and Word applications

Preferred Skills

  • 5+ years stop loss underwriting experience
  • Enhanced knowledge of medical conditions and costs

Additional Notes

  • Occasional overtime may be needed especially during the fall busy season.

Perks

  • On site fitness center
  • Casual dress
  • 401k with a 2 year vesting period
  • Short and Long term Disability after one year of employment

Qualified candidates can send their resumes directly to HR@imglobal.com.

About International Medical Group

For more than 25 years, International Medical Group -- headquartered in Indianapolis, Indiana, U.S.A. -- has provided global benefits and assistance services to millions of members in almost every country. We're committed to being there with our members wherever they may be in the world, providing them Global Peace of Mind®. With 24/7 worldwide assistance and medical management services, multilingual claims administrators and highly trained customer service professionals, IMG delivers the insurance products international members need, backed by the services they want. IMG's global family of companies includes Akeso Care Management®, IMG Europe Ltd., Global Response Ltd., IMG-Stop LossSM and International Medical Administrators, Inc.  Visit www.imglobal.com.

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DialysisPPO has Immediate Opening for a Regional Sales VP (Eastern US)

MyHealthGuide Source:  Mike Jeffers, VP, Sales & Account Management, DialysisPPO 4/20/2016, www.dialysisppo.com

DialysisPPO is seeking a sales professional to prospect, approach, present, follow up, and close deals. Ten years' experience in the healthcare benefits, cost containment, or medical stop-loss industry preferred.

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 expand our sales team by adding a Regional Sales VP in the eastern US. The position will be working from home with 25-50% travel in a defined territory.

Job Qualifications

  • Minimum of 5 years of experience in the healthcare benefits, cost containment, or medical stop-loss industry
  • Existing contacts in the TPA, stop loss, retail broker, Union verticals strongly desired
  • Disciplined, experienced, motivated self-starter
  • Sales, communication and relationship-building skills
  • Microsoft Office proficiency required
  • Must clear a background check
  • College degree preferred

If interested, please email us your resume to careers@dialysisppo.com.

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 www.dialysisppo.com.

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Market Trends, Studies, Books & Opinions


Survey Finds Independent TPAs Preferred

MyHealthGuide Source: Kevin Weinstein, 4/28/2016, Valence Health

Valence Health, a leading provider of clinical integration, population health, and value-based solutions and services, and the American Society for Healthcare Human Resources(ASHHRA), announced new research indicating that healthcare providers increasingly use their employee health plans as laboratories for value-based innovations.

The survey, conducted with human resources and finance executives at more than 150 hospitals, health systems and other provider organizations, found that narrow networks, site of care utilization, benefit design and physician incentive models are increasingly part of employee health plans.

"This research confirms what many industry insiders have seen regarding provider's assumption and management of financial and clinical risks," said Valence Health CEO R. Andrew Eckert. "Aligning incentives, controlling costs, being transparent with clinical outcomes and involving patients in the care decisions are all aspects of today's well-run employee health plans. As a result, it's no surprise that many provider organizations innovate with their own employee plans and then transfer that knowledge to supporting the patient population."

Key survey findings

  • Over 75% of respondents self-insure their employees' healthcare. Of those that do not currently self-insure their employees' health, 25% indicated it is somewhat or very likely that they will switch to a self-insured approach next year
  • Of those who self-insure their employees, 54% looked to a traditional payor to administer their self-insured plan, while 36% look to an independent third-party administrator (TPA).
  • Those working with independent TPAs were significantly more satisfied, with 50% of those respondents being very satisfied, compared to just 34% who were very satisfied using a payor for administration
  • Cost remains the number one driver for healthcare providers when selecting an administrative partner for their self-funded plan
  • When evaluating their administrative partners, provider organizations are least satisfied with Medical Management services

Valence Health will be conducting a webinar to review and discuss the survey results on Wednesday, May 25 at 12:00-1:00 pm CT. Sign-up for the webinar and/or download survey results now.

About Valence Health

Valence Health provides value-based solutions for hospitals, health systems and physicians to help them achieve clinical and financial rewards for more effectively managing patient populations. Leveraging 20 years of experience, Valence Health works with clients to design, build and manage customized value-based models including clinically integrated networks, bundled payments, risk-based contracts, accountable care organizations and provider-sponsored health plans. Providers turn to Valence Health's integrated set of advisory services, population health technology and value-based services to make the volume-to-value transition with a single partner in a practical and flexible way. Valence Health's more than 900 employees empower 85,000 physicians and 135 hospitals to advance the health of 20 million patients. Visit www.valencehealth.com.

About ASHHRA

Founded in 1964, the American Society for Healthcare Human Resources Administration (ASHHRA) is a personal membership group of the American Hospital Association (AHA) and has more than 3,100 members nationwide. ASHHRA leads the way for members to become more effective, valued and credible leaders in health care human resources. As the foremost authority in health care human resources, ASHHRA provides timely and critical support through research, learning and knowledge sharing, professional development, products and resources, and provides opportunities for networking and collaboration. ASHHRA offers the Certified in Healthcare Human Resources (CHHR), the only certification distinguishing health care human resource professionals.

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Legislative & Regulatory News


FAQs about Affordable Care Act Implementation (Part 31) - Prohibited Restrictions and Rescission Clarified

MyHealthGuide Source: Todd Leeuwenburgh, 4/26/2016, Thompson Blogs

Compliance with preventive health service requirements and other mandates of the health care reform law, along with disclosure obligations involving mental health parity requirements for health plans, were addressed in FAQ (frequently asked questions) issued by the U.S. Departments of Labor, Health and Human Services and Treasury on April 20.

Affordable Care Act compliance issues covered in FAQs about Affordable Care Act Implementation -- Part 31 include:

  • Plans and insurers may not impose cost sharing for the bowel preparation medications administered before preventive-screening colonoscopies are performed.
  • Plans may not retroactively terminate coverage by 2 months to exclude summer months under a school year calendar, when the work assignment lasted 10 months but the plan year was 12 months long.

    Example. A teacher who had paid 12 months of premiums announced on her last day of coverage that she did not intend to renew her contract; her last day actually working was two months before).

    Such a rescission of coverage is prohibited because (i) it had retroactive effect, (ii) it was not attributable to a failure to pay premiums on time, and (iii) there was no fraud or intentional misrepresentation.
  • Coverage for chemotherapy may not be limited just because it is being given in connection with a patient's participation in a clinical trial for a new anti-nausea drug. The chemo must be covered the same as it would have been without the clinical trial, if it typically would be covered, and was not: (1) experimental, investigational or the same service being studied in the approved clinical trial; (2) an item or service provided solely to satisfy the clinical trial's data collection and analysis needs; or (3) clearly inconsistent with widely accepted clinical standards of care.

    In addition, a plan that typically covers items and services to diagnose or treat complications may not deny coverage of these items and services to treat side effects from chemotherapy being administered through an approved clinical trial.

MHPAEA

Several of the FAQs discuss various requirements of the Mental Health Parity and Addiction Equity Act, which generally requires parity in financial requirements and treatment limitations between mental health/substance use disorder benefits and medical/surgical benefits.

One question was from a health care provider acting on behalf of a plan participant. The plan had asked the provider to complete a preauthorization form for the patient's mental health treatment. MHPAEA requires plans to disclose certain documents, and the provider asked which ones would be most helpful to verify the plan's compliance with MHPAEA.

The agencies responded that the plan would have to furnish the following documents if the provider requested them:

  • An ERISA summary plan description or similar summary information for non-ERISA plans.
  • Specific plan language on non-quantitative treatment limitations (such as a preauthorization requirement).
  • Information on how the NQTL applies to medical/surgical benefits.
  • All processes, evidentiary standards, and other evidence that went into determining that the NQTL applied to this particular mental health benefit, and the extent to which the limit also applied to medical/surgical benefits.
  • Any analyses on how the NQTL complies with the MHPAEA.

The FAQ states:

For example, if the plan can demonstrate that it imposes pre-authorization requirements for both [mental health] and medical-surgical benefits in the outpatient, in-network classification when the length of treatment for a condition exceeds the national average length of treatment by 10 percent or more, it has identified a factor on which the non-quantitative coverage limitation is based.

Since the plan requires a pre-authorization form after the patient's eighth mental health visit, the plan would want to prove that the national average length of outpatient treatment for this diagnosis is eight visits, the FAQ said. Also, when seeking to enforce its limit, the plan needs to produce documentation on how the rules for medical/surgical benefits were developed and applied, and demonstrate that they're not being applied to mental health benefits more stringently than to medical/surgical benefits. A plan may not withhold its standards for doing so on the basis that the information is proprietary or commercially valuable.

Another FAQ indicated that plans are expected to cover medication-assisted detoxification and/or maintenance treatment in combination with behavioral health services for opioid addiction.

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The Phia Group Webinar - Unraveling FAQ Part 31

MyHealthGuide Source: The Phia Group, 4/28/2016, www.PhiaGroup.com

  • Monday, May 2nd, 2016
    3:30 PM (EST) to 4:30 PM
    Registration

Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now; in its latest FAQ, published just last week (FAQs about Affordable Care Act Implementation, Part 31), the regulators reiterate concerns regarding network adequacy and how it relates to - and regulates - reference-based pricing arrangements.

Join us on Monday, May 2, at 3:30pm (EST) as The Phia Group's legal team and special guest Tim Martin of Payer Compass help unravel the mystery of the DOL's latest FAQ - and what it means for you and your plans.

About The Phia Group

The Phia Group, LLC is an experienced provider of health care cost containment techniques offering comprehensive consulting services, legal expertise, plan document drafting, subrogation and overpayment recovery, claim negotiation, and plan defense designed to control costs and protect plan assets. Visit www.PhiaGroup.com

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In Challenge To ‘Balance Billing', Judge Orders Hospital to Accept 25%

MyHealthGuide Source: Peter Vieth, 4/22/2016, Virginia Lawyers Weekly and Brooke Murphy, Becker Hospital Review

Article included in  Bill Rusteberg's RiskManager.us Blog.

For what may be the first time in Virginia, a judge has ordered a hospital to slash its "balance billing" charges by 75 percent to reflect the hospital's usual write-off for uninsured patients.

In a balance billing dispute with a patient, a judge has ordered Martinsville (Va.) Memorial Hospital accept 25 percent of its chargemaster rate as payment-in-full for care provided to a patient with coverage from a non-contracted insurer, reports Va. Lawyers Weekly.

Memorial Hospital is owned by Brentwood, Tenn.-based LifePoint Health.

Below are five things to know about the lawsuit.

  1. After experiencing chest pains, Glenn Dennis was rushed by ambulance to Memorial Hospital where he received emergency care for a heart attack. Mr. Dennis' attorneys said he spent two days in the hospital, during which he underwent surgery to place five stents in his arteries, according to the article.
  2. The hospital said Mr. Dennis' bill totaled $111,115.37 Mr. Dennis' insurance did not have a negotiated contract with Memorial for reduced reimbursement rates. The patient and insurer paid a combined $27,254, which Mr. Dennis contended was sufficient reimbursement.
  3. In response, Memorial sued Mr. Dennis for the outstanding $83,860.42 on his account and demanded the patient pay the amount in full.
  4. In court, Mr. Dennis argued his payment was sufficient because the hospital accepts 25 percent of prices specified in its chargemaster as payment-in-full for care to uninsured patients.
  5. In an opinion issued March 31, the judge ruled the reasonable value of Mr. Dennis' medical care was $27,778. The patient would owe the hospital $523.89 in addition to his previous payments.

The decision is rare judicial rebuke to the common hospital practice of billing full rate for patients whose insurance plans do not have negotiated contract rates.

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Medical News


Consumer Perceptions of Interactions With Primary Care Providers After Direct-to-Consumer Personal Genomic Testing

MyHealthGuide Source: Cathelijne H. van der Wouden, BSc, el at., Impact of Personal Genomics Study Group, Annals of Internal Medicine

A comprehensive picture of Direct-to-Consumer Personal Genomic Testing (DTC PGT) consumers who shared their results with a health care provider is presented. The proportion that shares results is expected to increase with time after testing as consumers find opportunities for discussion at later appointments or if results become relevant as medical needs evolve.

Direct-to-consumer (DTC) personal genomic testing (PGT) allows individuals to learn about their genetic makeup without going through a physician, but some consumers share their results with their primary care provider (PCP).

The study involved 1,026 DTC PGT consumers.  Researchers measured consumer satisfaction with the DTC PGT experience; whether and, if so, how many results could be used to improve health; how many results were not understood; and beliefs about the PCP's understanding of genetics. Participants were asked with whom they had discussed their results. Genetic reports were linked to survey responses.

Study findings

Among 1,026 respondents,

  • 63% planned to share their results with a Primary Care Provider (PCP).
  • At 6-month follow-up, 27% reported having done so, and 8% reported sharing with another health care provider only.
  • Common reasons for not sharing results with a health care provider were that the results were not important enough (40%) or that the participant did not have time to do so (37%).
  •  Among participants who discussed results with their PCP, 35% were very satisfied with the encounter, and 18% were not at all satisfied.
  • Frequently identified themes in participant descriptions of these encounters were actionability of the results or use in care (32%), PCP engagement or interest (25%), and lack of PCP engagement or interest (22%).

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Recurring Resources



Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 4/16/2016)

MyHealthGuide 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 update is encouraged.
Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com
  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
(Millions)
Capital/Equity
(Millions)
1 CIGNA     $2,701
2015
 
  Source - CIGNA Financial Supplement 2015, P.5 12/31/2015
2 Sun Life Financial     $1,034
2014
 
  Source - 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+)
$907
2015
$29,700 as part of Tokio Marine Group
  Source - Daniel Strusz, 1/25/2016
4 Voya Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
$807
2015
$396
12/31/2015
  Source - Joe Keller, Lead Financial Analyst, Voya Employee Benefits, 3/28/2016
5 HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
$751.4
2015
$588
12/31/2015
  Source - Matt Rhenish, President & COO, 2/19/2016
6 Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
$728
2014
$3,360.6
12/31/2014
  Source - Symetra 4Q 2014 Financial Supplement;
Tom Doran, President, Medical Risk Managers, Inc., 2/9/2015
7 Companion Life > 20 Years   $440
10/8/2014
 
  Source - Philip Gardham, Vice President, Specialty Markets, 10/8/2014
8 Swiss Re Corporate Solutions   Standard Security life Insurance Company of New York, Westport Insurance Corporation and Independence American Insurance Company $324
3/31/2016
 
  Source - Swiss Re Corporate Solutions Accounting Department
9 National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $253
2/1/2016
 
  Source - Jeff Gavlick, FSA, FCA, VP, Stop Loss Products, AIG Benefit Solutions, 2/1/2016
10 Zurich North America     $150  
  Source - Joseph Byers, Zurich North America, 4/6/2015
11 Munich Re Stop Loss, Inc.   American Alternative Insurance Company (AAIC),
TransAmerica
$147
2015
 
  Source - Travis Micucci, the Chief Executive Officer of Munich Re Stop Loss, Inc., 11/09/2015
12 United States Fire Insurance Company 15   $120
2015
$1,200
  Source - Lauren Woods, VP Marketing Fairmont Specialty, 1/4/2016
13 The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
$104
12/2014
 
  Source - Victor Moran, Second Vice President, Actuarial Operations.  3/6/2015
14 Gerber Life Insurance Company   Gerber Life Insurance Company $35
2016
$6,800
  Source - Gerber Life Insurance Company Stop Loss Director Job Description.  4/11/2016
15
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $3,388
12/31/2011
  Source - Mark Nichols, Managing Director.  7/20/2012

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

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

Stop-loss Premium Volume is not the Whole Story

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

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

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

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The Value of Self-Funding

MyHealthGuide Source:  The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, www.SIEFOnline.org 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 www.SIEFOnline.org.

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ICD-10 Readiness Tools

MyHealthGuide Source:  Industry Study Group (ISG), 9/19/2015

In the early 2000s a group of industry professionals collectively known as the Industry Study Group ("ISG") created a Standard Disclosure Notification form and a standardized list of ICD-9 diagnosis codes, known as the Trigger list. On October 1, 2015, our industry transitions to the new ICD-10 coding system. The ISG has once again undertaken the development of a new Trigger list based on the ICD-10 diagnosis codes. Please find links to the ISG White Paper on the process and to the new ICD-10-CM Trigger list

  • The new ICD-10-CM Trigger list is endorsed by SIIA and HCAA and supported by SPBA.  
  • Below are useful links for members of the self-funded community including TPAs, stop-loss carriers, MGUs, and others.

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    Upcoming Conferences


    May 2, 2016 - Webinar - 3:30 PM (EST) to 4:30 PM
    Unraveling FAQ Part 31 presented by The Phia Group.  Reference-based pricing is unquestionably a hot topic in the self-funded industry today. So hot, in fact, that the federal government has taken an active interest in it for the third time now; in its latest FAQ, published just last week (FAQs about Affordable Care Act Implementation, Part 31), the regulators reiterate concerns regarding network adequacy and how it relates to - and regulates - reference-based pricing arrangements.  Join us on as our legal team and special guest Tim Martin of Payer Compass help unravel the mystery of the DOL's latest FAQ - and what it means for you and your plans.  Registration.

    May 4-6, 2016
    15th Annual Health Literacy Conference
    presented by The Institute for Healthcare Advancement's (IHA).  Anaheim, CA. One-day and Two-day conferences presents practical and effective solutions to health literacy challenges, ranging from how to write and design effective communication, to tools for addressing low health insurance literacy skills.  Emphasis on ACA-related programming. The conference will attract health educators, health insurance agents, physicians and nurses, hospital representative, academics, writers, researchers and public health workers among others interested in the health literacy field. The conference also offers up to 20 continuing education credits to attendees.  www.iha4health.org

    May 11-13, 2016
    Northshore's 27th Annual Claims Conference presented by Northshore International Insurance Services, Inc. This is an invitation only event. If you are interested in attending, or presenting at next year's conference, you may contact Steve Murphy at smurphy@niis.com or Susan Arsenault at sarsenault@niis.com. Salem, Massachusetts.

    May 18-19, 2016
    Self-Insured Taft-Hartley Plan Executive Forum  presented by Self-Insurance Institute of America. Designed to help Taft-Hartley health plan administrators and trustees better understand all of the self-insurance strategies available to them that can help control costs while providing benefits to workers in the most efficient way. Speakers include Terry O'Sullivan, general president of the Labors' International Union of North America (LIUNA), Ed Smith, ULLICO CEO, Ed Kaplan, SVP and national health practice leader for The Segal Company, Adam Russo, CEO of the Phial Group, LLC, Cody Purdy, employee benefits consultant with IMA, Inc., Colleen Savoie, principal with Parker, Smith & Feek, Inc., David Chapman, president of Phoenix Benefits Management.  Sponsors contact:  Justin Miller at jmiller@siia.org. Information and registration: www.siia.org/i4a/pages/index.cfm?pageID=6826. Chicago, IL. Call 800-851-7789 and visit www.SIIA.org.

    May 23-26, 2016
    WEDI 25th Annual National Conference presented by Workgroup for Electronic Data Interchange.  This forum is designed to facilitate the groundwork underlying the future of healthcare information exchange. WEDI provides multi-stakeholder leadership and guidance to the nation's healthcare system on how to use and leverage the industry's collective technology, knowledge, expertise and information resources to improve the administrative efficiency, quality and cost effectiveness of healthcare information. Grand America Hotel, Salt Lake City.  Information and Registration

    May 24-25, 2016
    Self-Insured Workers' Compensation Executive Forum presented by Self-Insurance Institute of America. The educational program weaves together a collection of compelling topics including "big data" applications for claims management, how wellness programs can help control workers' comp costs, alternatives to statutory workers' comp, medical "over-diagnosis," SIG tax updates, and developments contributing to the erosion of exclusive remedy.  Rounding out the program, a variety of hot topics will be addressed as part of an "Out Front Ideas" session, and also during a separate "Battle of the Bloggers" session, featuring several of the leading workers' compensation industry commenters. These sessions promise to spark lively discussions that you will not want to miss.
    Scottsdale, AZ. www.SIIA.org

    May 25-26, 2016
    12th Annual Canadian Captives and Corporate Insurance Summit presented by Captive Insurance. Sheraton Centre, Toronto, ON. Event for current and prospective captive owners, captive managers and other professionals working in risk management and corporate insurance. Information and registration: www.captivesinsurance.com/attending/download-brochure/

    June 13-15, 2016
    AMS Claims Symposium, an invitation-only event presented by Advanced Medical Strategies. Mohegan Sun, Uncasville, CT. Contact Adria L. Garneau, CEBS, agarneau@mdstrat.com and visit www.mdstrat.com.

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

    July 19-21, 2016
    MCIA Eleventh Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA). This year's program will feature key captive regulators, captive owners and leading service providers addressing a variety of timely educational topics. The conference also serves as the premier networking event for those doing captive insurance business (or would like to) in the growing Montana captive domicile. Lodge at Whitefish Lake, Montana. (www.lodgeatwhitefishlake.com). Block of reserved rooms released on May 18, 2016. Contact Shane Byars at 866/388-6242, or sbyars@mtcaptives.org.  Visit www.mtcaptives.org.

    September 25-27, 2016
    36th Annual National Educational Conference & Expo presented by Self-Insurance Institute of America. Austin, TX. www.SIIA.org 

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

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

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

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

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    Editorial Notes, Disclaimers & Disclosures


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