General & Company News
Market Trends, Studies, Books & Opinions
Legislative & Regulatory News
Editorial Notes, Disclaimers & Disclosures
General & Company News
Yottaflow & KU Software Formalize Partnership to Streamline Stop Loss
MyHealthGuide Source: Yottaflow, 8/28/2015,
CLEVELAND -- kusoftware, developer of The Ugan System, and Yottaflow are
excited to announce a formal partnership with the goal of simplifying stop
loss for TPAs, MGUs, and Carriers. Through this partnership, Yottaflow and
kusoftware will coordinate and automate data exchange between TPAs and
MGUs/Carriers in connection with all stop loss processes including RFPs,
potential claim/trigger diagnosis notifications, and claim submissions.
Leveraging the strengths of both companies, Yottaflow and kusoftware will
deliver an integrated system that focuses on simplicity and ease of use
while providing powerful features at a competitive price.
"We want to streamline work for those involved with stop loss on a daily
basis. At the same time, we want to provide much needed visibility into the
claim submission and RFP process", said Mike Farley, Yottaflow's President.
Kevin Ugan, kusoftware's President adds "the interaction between TPAs, MGUs,
and carriers is too cumbersome and time consuming and we aim to make it
easier for everyone."
This partnership is more than just a handshake agreement. As part of the
arrangement, kusoftware has acquired an equity stake in Yottaflow.
About kusoftware & Yottaflow
kusoftware is one of the leading developers of complete, integrated
underwriting and administration software systems for MGUs and Carriers. The
company, based in Atlanta, Georgia, has been developing custom software for
businesses since 1989. Visit www.kusoftware.com.
Yottaflow is a web-based software application that simplifies the way TPAs
track and manage stop loss RFPs, claims and notifications. Yottaflow is
based in Cleveland, Ohio. Contact Mike Farley at
firstname.lastname@example.org, 216-245-7160 and
United Claim Solutions (UCS) Offers Dramatic Savings through its High Dollar
MyHealthGuide Source: United Claim Solutions (UCS), 8/28/2015,
PHOENIX, AZ -- United Claim Solutions (UCS), an innovative
Medical Cost Reduction and Claims Flow Management company has developed a
proven program that generates dramatic savings on high dollar claims
including Dialysis, SurgiCenters, Air Ambulance and Behavioral Health
"We've recognized that the utilizing the status quo process of accessing
Wrap and Supplemental PPOs to obtain discounts on specific high cost
services and associated providers is no longer an option. Consequently,
we've developed an innovative approach that yields significantly greater
savings on high cost services including dialysis, surgicenters, air
ambulance and behavioral health facilities," said Joshua Carder, President.
"Depending on the service and the provider we're securing savings that range
from 50-90% off billed charges."
UCS manages all provider inquiries on behalf of its Clients, making the High
Dollar Claim Solution a simple and effective program for Clients to
United Claim Solutions is an innovative Medical Cost Reduction and Claims
Flow Management company providing cutting edge and customizable programs for
payers, employers, labor organizations, reinsurers, and health plans. UCS
offers end to end services including Bill Review, Out-of-Network Bill
Repricing, Bill Edits, Medicare Plus Repricing, PPO Administration, Medical
Management, Clearinghouse Services, Data Warehousing, OCR/Scanning, and Plan
Modeling. We provide solutions for Group Health, Workers' Compensation, and
Auto Liability. Contact UCS if you are looking for:
• A partner that puts Service first
• Industry leading Savings on medical bills
• Flexible Solutions that reduce administrative costs
For more information contact Corte Iarossi, VP of Sales & Marketing at
866-762-4455 x 120, or via email at
Gary Tipton Passes
MyHealthGuide Source: 8/17/2015,
November 27, 1944 - August 17, 2015
Lakeway, TX -- Gary Harlan Tipton, 70, of Lakeway, Texas died on Monday, August 17, 2015
following a year-long brave battle with cancer. Gary was born on November
27, 1944 in Temple, Texas to Troy Harlan Tipton and Geneva Baker Tipton.
Gary was a visionary when it came to the design and implementation of new
health insurance models. While at Boon-Chapman in the late 70's, Gary worked
with the City of Austin and Bob Spurck to develop the first self-funded
health insurance program for municipalities in Texas. He developed many
Physician Hospital Organizations in the 80's. Gary also found time to expend
his talents as the editor of Texas Times magazine and dabble in the candy
factory business. Gary's creative mind, contagious smile and tremendous
sense of humor will be sorely missed.
Gary graduated from Waco High School and played football for the University
of Texas Longhorns from 1963 to 1965. While in high school, Gary was selling
life insurance after receiving special permission to take the licensing test
before the legal age of 18. He served in the Texas National Guard as a Mess
Steward and Jump Master for the 3rd Battalion, 143rd Infantry from
1968-1971. Upon receiving his Bachelor's degree from Baylor University, he
went to work selling life insurance for Texas Life achieving a place at the
Million Dollar Round Table. He then began working in the Health Insurance
Industry as an insurance consultant. He has resided in Waco, Austin, San
Antonio, Canyon Lake, and, most recently, Lakeway, Texas.
His hobbies and interests included hunting, fishing, boating, riding his
Harley and mountain bike, cooking, traveling, and wood working. He was quick
to give a helping hand to anyone who needed it. Gary had a way of lightening
the mood during social gatherings. His positive energy, fascinating stories
and good-hearted character permeated the room often making him the center of
attention. One of Gary's most admirable attributes was his ability to
develop strong bonds with people in such a short amount of time. He had a
way of communicating not only with people, but also dogs. He had a very
special place in his heart for his companion, Bullet. More than the
activities themselves, he loved the opportunity to get together with family
and friends over great food, a few beers, and Fox News in Tip's Tavern on
As you all know, Gary had very strong opinions about politics and life in
general, and his last wishes were no exception. He insisted there would be
no formal funeral service. Instead he requested that as friends and family
come together at future gatherings, they remember him by sharing memories.
We would like to use this website to post your stories or pictures of Gary
as a tribute to his life. Please join in the celebration and send your
stories and pictures to email@example.com.
In lieu of flowers, the family requests that donations be sent to
Austin or a charity of your choice.
He fought the good fight and now the words of Isaiah 40:31 apply, "but those
who hope in the Lord will renew their strength; they will soar on wings like
eagles, they will run and not grow weary, they will walk and not be faint."
Munich Health North America Announces the
Hiring of Dawn Carlsgaard
MyHealthGuide Source: Munich Health North America, 08/24/2015,
Princeton, NJ -- Munich Re announced that Dawn Carlsgaard has joined
the Munich Health North America reinsurance team as a Managed Care
Underwriter in the Managed Care and Reinsurance Solutions unit.
Dawn brings over 20 years of experience in underwriting and account
management experience in the healthcare reinsurance industry. Dawn will be
based in the Minnetonka, Minnesota office, where she will be responsible for
underwriting and expanding our Medical Excess line of business. She will
monitor the in-force coverage, as well as develop and enhance strong
relationships with the brokerage community.
Ken Wojack, Vice President of HMO Re Underwriting, says:
"We are excited to have Dawn join our staff in the Minneapolis area. Her
technical expertise and experience in underwriting and account management
will help Munich Health grow this key line of business."
Dawn has a strong background in managed care underwriting, beginning at
Fortis, and then working at ING Re, StarLine Group, and IOA Re, gaining
experience in underwriting HMO Reinsurance and Provider Excess insurance and
creating lasting relationships with the brokerage community.
About Munich Health
Munich Health is one of three business segments of Munich Re. Here all
international health care business in insurance and reinsurance operations,
as well as related services are pooled under the Munich Health brand.
Steve Fedele, Marketing Manager, at (609) 243-4238,
Data Dimensions Welcomes R. Ted Hailer as Program Director
MyHealthGuide Source: Data Dimensions, 8/25/2015,
JANESVILLE, WI -- Data Dimensions is proud to announce the
addition of R. Ted Hailer to its Project Management Team as a Program
Before his arrival at Data Dimensions, Hailer most recently served as an
Insurance Systems Consultant at Pro Unlimited, where he worked closely with
a number of major Property and Casualty firms on their insurance systems.
Before that, Hailer worked for 26 years in various senior-level positions at
both Kemper and Unitrin Insurance, including Program Manager, Senior Project
Manager and Manager of Business Transformation Technology.
In addition to his business experience, Hailer has a strong military
background, having served in the United States Army National Guard as a
First Lieutenant, Tank Platoon Leader.
"Ted brings a wealth of knowledge and experience from the property and
casualty arena to Data Dimensions," said Jon Boumstein, President and CEO.
"He will be a strong addition to the Data Dimensions team, mentoring his
colleagues, providing insight as a subject matter expert and assisting with
business development opportunities in the insurance sector."
About Data Dimensions
Since 1982, Data Dimensions has been helping clients better manage business
processes and workflows by bridging the gap of automation, technology, and
physical capabilities. As an innovative leader in the area of information
management and business process automation, we provide a complete range of
outsourcing and professional services including mailroom management;
document conversion services; data capture with OCR/ICR technologies;
physical records storage and electronic retrieval services through our state
of the art Tier III data center. Contact Will Pfeifer,
Marketing Coordinator, at firstname.lastname@example.org, 800.782.2907
and visit www.datadimensions.com.
Data Dimensions is a portfolio company of HealthEdge Investment Partners,
LLC. HealthEdge is an operating-oriented private equity fund founded in
2005. HealthEdge's investment team has over 100 years of combined operating
experience as operators and investors. For more information on HealthEdge,
Axia Strategies Has an Immediate Opening for a Director of Pharmacy
MyHealthGuide Source: Axia Strategies, 8/27/2015,
Axia Strategies is experiencing rapid growth in our pharmacy benefits
management practice, a specialty consulting area supporting our clients in
the assessment, selection and ongoing management of the PBM's utilized to
address pharmaceutical cost trend. As a valuable member of our team, the
Director of Pharmacy Analytics will be responsible for the coordination of
pharmacy management analytical projects as conducted by Axia Strategies'
pharmacy consulting practice located in Minneapolis, MN.
Essential Duties & Responsibilities
- Coordinate all aspects of client-and vendor related project management
with the Account Executive to ensure client satisfaction and timely project
- Lead role in management and coordination of RFP and client PBM negotiation
- Coordinates the assignment of all projects across the data analyst team.
- Identify areas for improvements and implement those improvements.
- Assist in the identification of new products and implementation of those
- Meet with clients in person and telephonically to determine needs, provide
data, and solve problems
- Develop and provide technical leadership.
- Analyze client and prospect data for trends and issues.
- Manipulate and work with spreadsheets to gather and query data needed for
Rx claims analysis.
- Provide Rx trending and technical expertise to clients.
- Provide training, education, and guidance to Account Managers
- College degree or equivalent job related experience required
- Knowledge of pharmacy benefit industry
- Effective time management, written and verbal skills
- Ability to work well with team members, maintain confidentiality, remain
open to others' ideas and exhibit a willingness to try new things
- Ability to demonstrate accuracy and thoroughness and monitor own work to
- Advance MS Office and SQL skills
- Advance data analysis, analytical, problem solving skills
Interested candidates should email their resume to
About Axia Strategies
Axia Strategies is a Minneapolis-based managed care consulting and brokerage
firm, focused on the development of effective cost containment solutions on
behalf of our health plan, reinsurance and stop-loss carrier clients.
Established in 1998, Axia has developed marketplace-leading cost containment
support services in pharmacy benefit management, catastrophic claim
solutions and specialized medical management approaches. Visit
DialysisPPO has an Immediate Opening for a Regional Sales Manager (Locate
MyHealthGuide Source: Laura J. Haffner, Executive Vice President,
DialysisPPO 8/25/2015, www.dialysisppo.com
Regional Sales Manager – Midwest, Mid-Atlantic or Southwest
DialysisPPO is seeking a sales professional that understands what a sales
cycle is and how to appropriately and professionally prospect, approach,
present, follow up, and close a deal. At least ten years' experience in
Medical Stop Loss is strongly preferred, Cost Containment experience a plus.
DialysisPPO has been in business since 2006. We have a stellar reputation in
the cost containment and management of End-Stage Renal Disease ("ESRD")
claims. We are the only company with a patented process. We provide
unmatched high-level cost containment services to self-funded companies of
all sizes that need and want to manage one of the highest cost drivers in
their Medical programs, ESRD claims.
We are a very unique and boutique firm, and are looking to place Regional
Sales Managers in various parts of the US. The Midwest is preferred;
however, for the right candidate, we will consider all areas of the country.
The individual will report to the Executive Vice President, located in
Seattle, WA. The position will be working from home with 25-50% travel in a
defined territory. We will provide full training, necessary materials, sales
leads and data in order that our Regional Sales Managers will be able to
prospect, present and educate any potential client about DialysisPPO's
unique value proposition.
- Minimum of 10 years of experience in sales of products and/or services in
the Medical Stop Loss, employee benefits or cost containment space
- Existing contacts in the TPA, stop loss, retail broker, Union verticals
- Professional designations such as CEBS are desirable
- Disciplined, experienced, motivated self-starter
- Sales, communication and relationship-building skills
- Microsoft Office proficiency required
- Must clear a background check
- College degree preferred
To be considered for this position, candidates must have previous work
experience in sales and an understanding of products and verticals including
Medical Stop Loss, Third Party Administrators, Employee Benefits, Retail
brokers, etc. Must maintain own medical coverage; no employee benefits or
401(k) plan currently available.
If interested please email us your resume to
we receive your resume we will follow up and let you know if you're being
considered for the position. We will also include more information about our
firm's services and expertise.
We look forward to hearing from you.
DialysisPPO helps group health plans and their partners manage the
exceptionally high cost of dialysis cases for the treatment of End-Stage
Renal Disease. Our patented program enables plans to capitalize on the
unique Medicare reimbursement aspects of this costly disease, yielding
average client savings of $590,000 per dialysis case annually. Visit
HIIG Elite Underwriting Has an Immediate Opening for a Chief Actuary
MyHealthGuide Source: Houston International Insurance Group (HIIG), 8/17/2015,
Join our growing team! Houston International Insurance Group (HIIG) made a
strategic acquisition to acquire Elite Underwriting and is looking to
aggressively expand. We are excited to be growing our Accident and Health
division. At HIIG-Elite, we consider every employee to be a valuable part of
our company. Our continued success is a direct result of our team's industry
expertise and hard work.
This position of Chief Actuary can be located in in our Malvern, PA,
Indianapolis, IN, Wakefield MA or Houston, TX locations.
Essential Duties and Responsibilities
- Lead pricing, reserving, product development and forecasting for Accident
& Health products. Experience with voluntary lives and supplemental health
products a plus.
- Work on pricing models, reserve studies, management reporting, financial
forecasting, business strategies and other assignments.
- Develops the basis for and analyzes advanced actuarial studies for health
or group insurance (e.g. morbidity, mortality, lapses, expenses, financial
results, selection, secular trends, claims utilization, cost factors and
reserve adequacy) to determine premiums, rates, coverages, reserves and
financial statement liabilities
- Works in conjunction with other departments in response to changing market
conditions and net market opportunities.
- Leads special projects and is involved in evaluation of acquisition
- Provides consultation of data to various audiences; able to communicate
technical data to audiences with various levels of understanding.
- Participate in Board level presentations about current business and future
HIIG Elite offers
- A competitive base salary
- Leadership development through individualized support and mentoring
- Medical benefits, STD/LTD, Life, Dental, Vision, 401k, PTO
Interested candidates should email their resume to
HIIG is a Houston based, rapidly expanding insurance group that provides
creative solutions for our clients' specialized needs. HIIG writes business
throughout the USA and Internationally through its underwriting divisions
that include Accident & Health, Construction, Energy, Professional,
Transactional Property, and other Specialty business.
HIIG Elite is our Accident & Health Division and we are seeking an
experienced Chief Actuary who is self-motivated and possess a strong
entrepreneurial spirit...let us hear from you !! We hope you will consider
joining the Team. Visit www.hiig.com.
Market Trends, Studies, Books & Opinions
Waking Up to the Opportunity of Self-Funded Employee Health Benefits
MyHealthGuide Source: Carol Berry, CSFS , 8/24/2015,
American Journal of Managed
The self-funded employee health benefits market is a sleeping giant.
Programs in which companies finance their employees' healthcare with their
own assets are becoming increasingly prevalent, as employers seek ways to
reduce ever-escalating expenses, manage risks, increase flexibility of their
plans, and tailor plans geared toward what their workers really want and
need, all within the confines of the Affordable Care Act (ACA).
With organizations' healthcare expenses are poised to jump by almost 7% in
2015, according to PricewaterhouseCoopers' Health Research Institute,
self-funding can be an alternative to help a company control how much it
spends on employee health benefits, while providing workers with quality
Almost 95% of US companies with at least 5000 employees currently self fund
their health benefit plans. However, the industry that was once mostly
thought to be only the domain of large companies, like Walmart, Microsoft,
and Starbucks, is now changing. Today, the self-funded market, regulated by
the Department of Labor and under the protection of the Employer Retirement
Income Security Act, now includes nearly 60% of US employers of all sizes.
The ACA is fueling the proliferation of self-funding by adding new costs on
fully insured plans and eliminating the risks typically associated with
self-funding. Many self-funded healthcare plans are exempt from new taxes,
fees, and restrictions placed on fully insured medical plans by the ACA. So
employers with strong financials and stable work forces are increasingly
looking at transitioning to self-funding their employee benefits.
Some of the benefits that can be realized by developing a self-funded health
benefit plan include:
- Plan design flexibility
- Premium and healthcare cost savings
- Cost transparency
- And importantly, the availability of detailed analytics, which provide
information on fees, expenses, and costs not usually able to be provided by
fully insured plans
Self-funded plans hold down healthcare costs better than fully insured
plans. Once an employer has developed its self-funded program, with careful
planning and administration, it can expect to realize, on average, a 5% to
15% savings over participating in a fully insured plan.
We are often asked,
"How does an employer interested in self-funding the healthcare benefits
pursue it as an option?" If a company determines self-funding may be
appropriate, company leaders should:
- Engage an insurance broker or health
benefits consultant to guide the process;
- Do a cash flow and risk analysis
to determine the monetary resources available and the employer's risk
- Identify the plan benefits desired;
- Identify the amount and type
of stop loss coverage desired to protect against catastrophic or
- Discuss the types of additional benefits desired:
medical/case management, dental, vision, pharmacy benefit manager, flexible
spending account, wellness, etc.;
- Discuss the type of provider network
- And last, but certainly not least, companies moving to self-funding
will need to contract with a reputable third-party administrator (TPA).
TPA will work with the employer's broker/consultant, to bring all the
diverse pieces together in a cohesive benefit package and will provide the
administrative services, systems and process to implement the self-funded
plan. There are many important players in the self-funded community,
including stop loss carriers, networks, medical managers, wellness
companies, legal counsel, compliance companies, underwriters, audit firms,
healthcare systems, brokers, human resource managers and consultants.
Selecting the right TPA is a critical addition to the team and is critical
to the success of an employer's self-funded plan.
Carol Berry, CSFS is the chief executive officer for the
Health Care Administrators
Association (HCAA), and has more than 35 years' experience in the healthcare
and software industries. She has held a variety of executive positions in
self-funding, managed care, managed behavioral health, and group medical
insurance, including principal of Lockhurst Consulting, director of account
services for Coastal TPA, and senior vice president of HealthLogic Systems
Legislative & Regulatory News
State Law Claim for
Invasion of Privacy Escapes ERISA Preemption
MyHealthGuide Source: Mark S. Thomas, 8/27/2015,
Case: Rose v. HealthComp, Inc., No.
1:15-cv-00619-SAB (E.D. California, August 10, 2015)
Article referred by John H. Eggertsen,
Attorney at Law,
Eggertsen Consulting, Inc.
A federal court recently held that the plaintiff's claims under state law
survived ERISA preemption, and remanded the case to state court to determine
the plaintiff's claims for invasion of privacy and unfair business practices
arising from the administrator's disclosure of her medical records to her
employer. While rooted tightly to its facts, above Rose illustrates some of
the limits to the otherwise broad reach of ERISA preemption.
The plaintiff ("Rose") was employed in California by Harris
Ranch Beef Company ("Harris Ranch") for over eight years, to late 2012, and
was enrolled in Harris Ranch's self-insured employee health plan. The
defendant, HealthComp, Inc. ("HealthComp"), was the plan's third-party
administrator and, in that fiduciary role, provided case management
services. As part of these services, HealthComp notified Harris Ranch when
HealthComp saw an employee's health costs rising, and also assigned a nurse
case manager to work with an employee in an effort to hold down health
Rose suffered from medical issues for years, leading in December 2011 to
hospitalization for treatment and diagnosis of liver failure. Her doctors
determined that she needed a liver transplant and placed her on a transplant
waiting list. Rose alleged, in this case, that in March 2012, without her
permission, HealthComp notified Harris Ranch of her medical condition and
need for a liver transplant. HealthComp assigned Rose a nurse case manager,
and Rose signed a medical release form for that case manager; Rose alleged
in this case, however, that she was not told that her medical information
would be shared with her employer.
In December 2012, HealthComp sent Harris Ranch a report that Rose's need for
an expensive liver transplant had increased. Harris Ranch terminated Rose
shortly after it received that report, and HealthComp closed its case
management file on Rose. Rose later filed a lawsuit against Harris Ranch.
HealthComp then reopened its file; Rose alleged, in this case, that
HealthComp used its prior medical authorization release to then review her
medical records and furnish information to Harris Ranch.
Rose then sued HealthComp under California law in California superior court,
alleging invasion of privacy and unfair business practices arising from
unauthorized disclosures of her medical information to Harris Ranch.
HealthComp removed the case to federal court, asserting that the claims were
preempted by ERISA. Rose then filed a motion to remand the case to state
The Court's Ruling
The federal courts have long held that the scope of
ERISA's preemption of state law is very broad in order to achieve the
Congressional goal of providing a uniform regulatory scheme for
ERISA-governed employee benefit plans. All state law claims that come within
the scope of ERISA preemption are displaced by the federal statute and
converted into federal claims under ERISA's civil enforcement provision,
section 502. That is, the claimant then has the remedies ERISA's section 502
would allow, if any, and not the remedies provided under state law. The
question in Rose was whether the plaintiff's state law claims were subject
to that broad preemptive reach.
The Rose court held that under the U. S. Supreme Court's decision in
Health Inc. v. Davila, 542 U. S. 200 (2004), and the U. S. Court of Appeals
for the Ninth Circuit's subsequent decision in Fossen v. Blue Cross & Blue
Shield of Montana, Inc., 660 F.3d 1102 (9th Cir. 2011), the district court
had to apply a two-part test to determine whether Rose's state law claims
- Under that test, a state law claim would be preempted if,
first, the individual, at some point in time, could have brought the claim
under ERISA section 502(a)(1)(B)(for civil claims by plan participants and
beneficiaries to recover plan benefits, obtain a declaration of rights under
the plan, etc.), and,
- Second, there is no other independent legal duty
implicated by the defendant's actions.
The Rose court decided that the case met the first part of the Fossen test.
For comparison, the court noted the holding of the U. S. Court of Appeals
for the Fourth Circuit in Darcangelo v. Verizon Communications, Inc., 292
F.3d 181 (4th Cir. 2002). The Darcangelo court held that "alleged misconduct
by an administrator that was clearly undertaken in the course of carrying
out duties under a plan" would be preempted by ERISA, but if the
administrator obtained an employee-participant's medical information and
informed the employer solely to assist the employer in determining whether
the participant was a threat to her co-workers, then state law claims
arising from that disclosure would "not be related to the plan". In Rose,
HealthComp obtained Rose's medical information while performing case
management duties under the plan, and then disclosed them to the employer
(improperly, according to Rose), and Rose could thus have alleged a breach
of HealthComp's plan fiduciary duties and pursued a claim under ERISA
section 502(a). This satisfied the first prong of the Fossen test.
Regarding the second part of the test, however, Rose asserted claims arising
under California's right of privacy that arose independently of either ERISA
or the plan terms. The court found that the state law claims did not arise
"but for" the administration of the ERISA plan, and those claims could have
been brought even if Harris Ranch's plan had not existed. The fact that
HealthComp would not have obtained Rose's medical information without the
existence of the Harris Ranch plan, did not create a sufficient relationship
with the plan under the Ninth Circuit's cases to justify preemption.
Because Rose's claims did not satisfy both prongs of the Fossen test, the
court granted Rose's motion to remand the case back to the state court for
The Significant Lesson
While each of the federal circuits will have its own
case precedents interpreting the Supreme Court's Davila holding, the ruling
in Rose is representative of the preemption analysis. It also points up the
seriousness of facts alleging the improper use of a participant's personal
medical information and the potential exposure of plans and their
fiduciaries when handling such information in this era of heightened
sensitivity to personal data disclosures. Rose thus indicates some limits to
ERISA's broad preemption doctrine in that scenario.
About the Author
Mark Thomas is a partner in the firm's Litigation Section. He
represents individuals and businesses in connection with ERISA and other
employee benefits disputes, trust litigation, lawsuits and registrations to
protect trademarks, copyrights and other intellectual property, and complex
business litigation. In addition, he counsels clients on the administration
of employee benefit plans. Visit
ERISA Administrative Appeal Denial Letters Must State
Plan-Imposed Time Limits
MyHealthGuide Source: Stacey Cerrone and Russell Hirschhorn,
Proskauer Rose LLP
Case: Mirza v. Insurance Administrator of America Inc., 2015 WL 5024159
(3d Cir. Aug. 26, 2015).
The Third Circuit recently held that ERISA administrative appeal denial
letters must include plan-imposed time limits for commencing a lawsuit
challenging the claim denial, and the failure to provide such notice
warranted setting aside the plan's limitation period.
The ERISA claims
regulation provides that adverse determination letters must provide a
"description of the plan's review procedures and the time limits applicable
to such procedures, including a statement of the claimant's right to bring a
civil action" for benefits. 29 C.F.R. § 2560.503-1(g)(1)(iv).
with the First and Sixth Circuits' rulings on this issue, the Third Circuit
determined that the regulation's "time limit" notice requirement applies not
only to periods pertaining to when a participant may file an administrative
appeal, but also to a plan-imposed limitation period for commencing a
lawsuit after an appeal is denied.
In so ruling, the Court reasoned that not
requiring such notice would permit administrators to "hide the ball" because
participants are more likely to read and rely on adverse determination
letters than lengthy plan documents. Having found that such notice is
required, the Court determined the proper remedy was to set aside the plan's
limitation period and to replace it with the most analogous state law
period, which the parties agreed was New Jersey's six-year limitation period
applicable to breach of contract claims.
Given that three circuits already have ruled consistently
on these issues, plan fiduciaries should make sure that administrative
appeal denial letters specifically set forth plan-imposed time limits.
Furthermore, given the courts' tendency not to penalize participants for
failure to consult SPDs and plan documents when pursuing a claim for
benefits, plan sponsors and administrators should consider whether there is
other information pertinent to the claims process to which they should
affirmatively alert participants when determining claims for benefits.
ICD-10: Coding for
Hypertension and Heart Disease
MyHealthGuide Source: Betsy Nicoletti, MS, 8/25/2015,
Medscape Business of
Medicine, WebMD, LLC
The change to ICD-10 provides the opportunity to more accurately report
hypertension, hypertensive heart disease, and hypertensive chronic kidney
Essential hypertension in ICD-10 has only one code: I10. Coders joke that it
is the one code they can easily memorize, because a complete ICD-10 code can
be up to seven characters long and is alphanumeric. Both 401.1 (benign
hypertension) and 401.9 (hypertension, not otherwise specified) will be
replaced by I10 -- essential (primary) hypertension.
There are specific codes to describe hypertensive heart disease,
hypertensive chronic kidney disease, and hypertensive heart and chronic
- If a physician determines that a patient has hypertension and heart
disease caused by the hypertension, list first the combination code for
hypertensive heart disease, either with or without heart failure.
- If the patient has heart failure, there is a notation to use an
additional code from the I50 category to identify the type of heart
- A patient with hypertension and chronic kidney disease is coded with
a code from category I12, hypertensive chronic kidney disease. I12.0 is
for hypertensive chronic kidney disease in a patient with stage 5 or
end-stage renal disease or I12.9 for hypertensive chronic kidney
disease, stage 1 through stage 4.
Coding Options Increase
And of course, add another code to describe the stage of the chronic kidney
disease. A coder may assume a causal relationship between hypertension and
chronic kidney disease, but may not assume a causal relationship between
hypertension and hypertensive heart disease.
If a patient has both hypertensive heart and chronic kidney disease, the
coding options increase. Then, select a code from the I13 category. The code
indicates whether the patient has heart failure or not, and the stage of the
chronic kidney disease. As in the previous situations, use additional codes
to identify the type of heart failure and the stage of the kidney disease.
Medical Stop-Loss Providers
Ranked by Annual Premium Survey (last updated 8/8/2015)
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
Stop-loss Premium Ranking
Compiled by MyHealthGuide Newsletter
Reader response and correction is
Sources will be cited. Please send updates /
changes to Info@MyHealthGuide.com
Years Providing Stop
Associated Carriers /
Annual stop-loss Premium
CIGNA Financial Supplement 2014, P.5 12/31/2014
||Sun Life Financial
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
||HCC Life Insurance Company
(A.M. Best Rated: A+)
(A.M. Best Rated: A+)
||HCC Insurance Holdings, Inc.
||HM Insurance Group
||HM Insurance Group
(A.M. Best Rated: A-)
Rhenish, President & COO, 2/16/2015
||Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
4Q 2014 Financial Supplement;
Medical Risk Managers, Inc.
Voya Employee Benefits
||> 35 Years
(A.M. Best Rated: A)
Lead Financial Analyst, Voya Employee Benefits,
||> 20 Years
||Philip Gardham, Vice President,
||Independence Holding Company
||Standard Security Life Insurance
Company of New York,
Madison National Life,
Independence American Insurance Company
||National Union Fire Insurance
Company of Pittsburgh
||AIG Benefit Solutions
Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
||Zurich North America
Joseph Byers, Zurich North America.
||Munich Re Stop Loss, Inc.
||Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
Union Labor Life Insurance Company (ULLICO)
(A.M. Best Rated: B++)
Second Vice President, Actuarial Operations.
||Markel Insurance Company
||Markel Insurance Company
(A.M. Best Rated: A-)
Mark Nichols, Managing
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
- Amalgamated Life
- American Fidelity Assurance Company
- American National Life Insurance Company of Texas
Accident and Health
- BEST Re
- Blue CrossBlue Cross Blue Shield (various regions)
- Gerber Life Insurance Company
- International Insurance Agency
- Lloyd's of London
- Nationwide Life Insurance Company
- Pan American Life
- QBE Insurance Company
- Trustmark Insurance Company
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:
Should reader interest indicate such measures are important, this
Newsletter will attempt to collect and report.
- Ratings from Best, S&P, Moodys and others
- Capital size of the insurance company
(data collection began
- 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
Reader response and correction is encouraged. Sources will be cited.
Please send updates / changes to Info@MyHealthGuide.com.
The Value of
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
September 10, 2015 - Webinar
2:00 pm ET
Cost-Containment Insights: Partnering to get the solutions you need
presented by Sun Life Self-funded employers (and those that are considering becoming self-funded)
continue to seek support on how to manage the cost of medical claims.
Designed for the third party administrators, brokers and nurse case managers
who support self-funded employers, webinar participants will hear from
cost-containment expert Mark S. Hartmann, EthiCare Advisors, Inc. CEO and
Brad Nieland, Sun Life Stop-Loss Vice President. They'll share insights on
the latest medical claim trends and cost-containment best practices that you
can use immediately.
September 10, 2015 - Webinar 1:00 pm EST
Predicting the Future of Claims Cost Analysis presented by
Strategies. Join us for a look at how technological innovation can
transform how you approach catastrophic claims.
In this 45 minute webinar you'll learn: How a data-driven approach to
processing catastrophic claims will increase efficiency, save time and save
money. How to access billed and paid data that gives you increased leverage
in negotiations. What technologies are reducing and eliminating the need for
outside vendor fees like underwriting, cost containment, and case
management. With new treatments and pharmaceuticals, complex claims are in a
constant state of re-evaluation and change, so please join us on September
10th for this cutting-edge presentation. Limited seating available.
September 14-15, 2015
Texas Association of Benefit Administrators Annual Fall Conference and
Membership Meeting. The Conference will be at the Crowne Plaza near The
Galleria in Addison, Texas. Contact
Phyllis Campbell at 512-507-7001 and
email@example.com. Information and registration:
September 14-16, 2015
Self-Insurance Executive Summit in London with Special Lloyd's Tour
presented by Self-Insurance Educational Foundation (SIEF). Join senior industry executives from the United States, the United Kingdom
and other major insurance marketplaces to share knowledge and facilitate
important professional connections in London.
Apex City of London Hotel. Conference information: 800-851-7789 and
September 14-16, 2015
2015 MCRA Annual
Conference presented by Managed Care Risk Association.
Terranea Resort, Palos Verdes Peninsula, California-overlooks the
Pacific Ocean and Catalina Island. Early bird conference fee is $650
through May 18, $750 afterwards. Hotel number is (866) 802-8000 and
mention "Managed Care Risk Association". See
www.mcraweb.org. The mission of
the Managed Care Risk Association is to support the health care
excess of loss reinsurance and provider excess markets by
facilitating information exchange between reinsurers, underwriters,
brokers, and cost containment providers.
September 17, 2015 -
1:00 PM (EST) to 2:00 PM (EST)
Phia Case Studies -When Silence is Loud and
Assumptions Mean Disaster presented
The Phia Group.
As employers look to self-fund with increasing frequency, expectations that
brokers, vendors, and third party administrators will take on more binding
authority are trending as well. Cases where an entity is held liable for
failing to uphold a responsibility it didn't intend to adopt are
consequently on the rise as well. These recent cases impact how you are (or
at least should be) handling claims.
Information and Registration
September 22, 2015 - Webinar
9:00 am PT/11:00 pm CT/12:00 pm ET
Snake Oil, Balderdash, and Hogwash: Searching for Truth in the Fraught Legal
Landscape of ERISA Today presented by
Health Care Administrators Association
Presenter: Josh Sears, founder, Freestone Corporate Law,
Chtd., based in Boise, Idaho. Josh's expertise includes ERISA, COBRA, HIPAA,
and the Patient Protection and Affordable Care Act.
ERISA has been operating efficiently for many years by providing employers a
framework from which to administer multi-benefit programs uniformly across
multiple states. But, state-based power-grabs, regulatory gobblely-gook,
high-court decisions, the fear-mongering of politicians (and even some
misguided folk within our own industry) challenge and threaten to erode the
very construct from which it has thrived so successfully for decades.
Understanding ERISA and impacts of the ACA on its mandates (for good and
ill) is of critical importance so you can assist in protecting this
framework and best serve your clients.
In order to be the most informed with the current legal challenges facing
our Plans with the advent of ACA, this overview will address the following
items: ERISA: State by State assault on pre-emption,
Federal Legal Developments,
Cadillac Tax and whether it is permissible as a non-fiduciary,
King v. Burwell decision update,
MEC & Skinny Plans,
Reference Based Pricing,
Brokers competing for your clients – (veiled "threat of exposure", wrap
documents, compliance). Webinar Registration:
September 28-30, 2015
SPBA Fall Meeting
Scottsdale, AZ. Society of Professional Benefit Administrators
October 18-20, 2015
National Educational Conference & Expo
presented by Self-Insurance Institute
• The Rise of Private Equity and Venture Capital in the
• Your Company and Its Future - Preparing for a Major Financial
• How does direct provider contracting work in the context of
medical travel arrangements;
• What hospital executives think about self-insured employer payment
• What has been the actual self-insured employer experience with
on-site health clinics;
• How self-insured health plans should start preparing for the ACA
• What venture capital and private equity firms are looking for when
considering acquisitions of companies active in the self-insurance
• Where all of the "big" health care claims have been coming from;
• The latest ACA compliance news;
• What to do if your plan becomes subject to a DOL audit;
• How do you determine whether reference-based pricing is right for
- Additionally, the schedule will include a "mock mediation" session
where attendees will have a front row seat to see what happens when
a self-insured group, a TPA and a stop-loss carrier have a serious
claims payment dispute. This promises to an extremely entertaining
and interactive session.
The health care sessions are part of a larger educational program
that includes nearly 40 general and breakout sessions related to the
broader self-insurance marketplace. This top-notch educational
program will be supplemented by the industry's largest exhibit hall
and incredible networking opportunities throughout the event.
Washington, DC. Call 800-851-7789 and visit
February 9-11, 2016
presented by Health Care Administrators Association (HCAA).
Senator Tom Daschle is opening keynote!
Senator Daschle will present "An Insider's View on
President Obama's Health Care Policy and Its Future" on Wednesday 2/10/16
from 9:00am - 10:30am. Caesars Palace, Las Vegas, NV.
Room rates: $220 / night plus tax (through 1/15/16).
Call 866-227-5944 and reference Health Care Administrators Association or
March 7-9, 2016
The Sixteenth Population Health Colloquium
presented by HC Conference. Philadelphia, PA and WEBCAST. Featuring Special Medical Home Track.
Troyen Brennan, MD, MPH,
Executive Vice President and Chief Medical Officer, CVS Health, Former Chief
Medical Officer, Aetna Inc., Woonsocket, RI. Bill Copeland, MBA
Vice Chairman and US Life Sciences & Health Care Industry Leader, Deloitte
LLP, Philadelphia, PA. Peter R. Orszag, Vice Chairman, Citigroup, Former Director, OMB (Obama), Former Senior
Economist, Council of Economic Advisers (Clinton), New York, NY
Phone: (800) 503-7439, firstname.lastname@example.org
March 30-April 1, 2016
SPBA Spring Meeting
Washington, DC. Society of Professional Benefit Administrators
July 13-15, 2016
TPA University 2016
presented by Health Care Administrators Association (HCAA). Renaissance Dallas, Dallas,
October 17-19, 2016
SPBA Fall Meeting
Minneapolis, MN. Society of Professional Benefit Administrators
February 8-10, 2017
Executive Forum 2017 presented by Health Care
Administrators Association (HCAA). Bellagio, Las Vegas, NC.
March 15-17, 2017
SPBA Spring Meeting
Washington, DC. Society of Professional Benefit Administrators
September 13-15, 2017
SPBA Fall Meeting
Cincinnati, OH. Society of Professional Benefit Administrators
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
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