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TABLE OF CONTENTS
INTERLINK® Centers of Excellence Adds The University of Alabama Hospital and Northside Hospital
MyHealthGuide Source: INTERLINK®, 5/19/2015, interlinkhealth.com
Hillsboro, OR -- INTERLINK® COE Networks & Programs is pleased to announce the addition of The University of Alabama Hospital and Northside Hospital as providers in full standing in the INTERLINK TransplantCOE Network. These additions represent a significant milestone for the INTERLINK Quality and Contract teams, with their combined 13 year effort yielding a national transplant network comprised of the finest centers. The INTERLINK TransplantCOE Network will rest at 82 transplant centers and 495 annually credentialed programs.
The University of Alabama Hospital (UAB) not only serves as the major transplant center for the Southeast region, but also attracts business from all parts of the nation. UAB provides an integrated line of transplant services, which include solid organ and bone marrow/stem cell transplantation. According to Cindy Mathews, RN, CCM, INTERLINK's Vice President, Quality Programs, "after completing our outcome data review, the on-site inspection and interviewing the transplant medical and surgical directors, I believe our network will be greatly enhanced and our membership benefited by getting their transplants at UAB."
The addition of Northside Hospital in Atlanta, Georgia completes INTERLINK's TransplantCOE network bone marrow strategy in the southeast region. "We're very excited to bring on the Northside program," says Ronald Potts, MD, Chief Medical Officer. According to Dr. Potts, "The attention to quality, details, patient experience and innovation were evident nearly the moment we walked into the door for our approval visit. It's clear why they achieve their outstanding outcomes in hematologic malignancies and stem cell transplantation."
"What an incredible journey this has been" says John Van Dyke, INTERLINK's CEO, "to build something so meaningful and relevant for plans, patients and providers. Outcome based care is the model for the future, and the processes INTERLINK has been perfecting with its providers is a template other medical providers and health plans can benefit from".
About INTERLINK® COE Networks & Programs
INTERLINK is a privately held corporation based in Hillsboro, Oregon. INTERLINK builds Centers of Excellence networks for high-cost, low frequency medical procedures which are utilized by health plans across the nation. INTERLINK's COE networks make available ACA adjusted benefit language, member education materials and fully integrated management. Call 800-599-9119 and visit interlinkhealth.com.
Helios, Pharmacy Benefit Manager, Acquires Medicare Compliance Unit
MyHealthGuide Source: Sheena Harrison, 5/18/2015, Business Insurance Article
Helios, a Memphis, Tennessee-based pharmacy benefit management and settlement services firm, has acquired Ringler Medicare Solutions Inc., a Medicare Secondary Payer compliance unit, the companies announced in a statement.
Ringler Medicare Solutions is a division of Aliso Viejo, California-based structured settlement firm Ringler Associates Inc., according to Friday's statement. Terms of the deal were not disclosed.
"The acquisition of RMS allows us to continue to expand our presence in the claim settlement market," said Jeff Gurtcheff, vice president and general manager of settlement solutions for Helios, in the statement. "The integration of RMS will further enhance our ability to work closely with all parties to assist in the identification of claim settlements where Medicare consideration is recommended, provide education and training to clients, and simplify the settlement process."
Helios brings the focus of workers' compensation and auto no-fault Pharmacy Benefit Management, Ancillary, and Settlement Solutions back to where it belongs—the injured person. This comes with a passion and intensity on delivering value beyond just the transactional savings for which we excel. Call 800.777.3574 and visit www.HeliosComp.com.
Symetra's Ratings Affirmed by Fitch
MyHealthGuide Source: Business Wire, 5/22/2015, www.Symetra.com
CHICAGO -- Fitch Ratings has affirmed the 'A+' Insurer Financial Strength (IFS) rating on Symetra Life Insurance Company (Symetra Life) as well as all ratings for Symetra Financial Corp. (Symetra), including the Issuer Default Rating (IDR) at 'A-' and all outstanding debt issues. The Rating Outlook is Negative.
Stop-Loss Contributes to Key Rating Drivers
Fitch's affirmation of Symetra's ratings reflects the company's strong balance sheet, consistent and diversified earnings, moderate financial leverage and lower-risk products. Additional strengths include the company's good competitive position in the group medical stop-loss market and fixed annuities sold through banks.
The ratings also consider Symetra's lack of significant scale compared to other highly rated life insurers, moderate profitability and lower fixed charge coverage compared to rating expectations and similarly rated peers. In addition, the company relies upon its group medical stop-loss business to generate a significant but sometimes volatile source of earnings.
The Negative Outlook is based primarily on Symetra's high exposure to the continuing low interest rate environment and the effect on profitability, GAAP based fixed charge coverage and additional statutory reserving related to asset adequacy testing over the next 12 to 18 months. The company's statutory reserves are adequate to support the policyholder contractual obligations under moderately adverse conditions as analyzed by year end 2014 cash flow testing results. Given its liability mix, Symetra is more exposed to this risk than peers due to its large legacy structured settlement and bank owned life insurance (BOLI) book. Longer-term, Fitch is concerned with the earnings implications of a prolonged low interest rate environment as spreads between earned rates and credited rates narrow.
Symetra's GAAP fixed charge coverage ratio is low for the rating, declining to 6.7X for the first three months of 2015 and 7.9x for full 2014. Fixed charge coverage is expected to be pressured in 2015 as interest expenses increase and earnings are challenged by low rates and the increase to normal loss ratios in the group benefits medical stop loss business. Statutory interest coverage based on maximum dividend coverage is expected to remain strong at over 4.7 times in 2015. In addition Symetra has approximately $100 million in committed cash at the holding company.
Symetra's profitability is below peers and moderate for the rating with operating ROE at 8-10% on a run rate basis. After GAAP profitability improved moderately to 9.6% for 2014, the company reported a decline in operating returns on equity to 6.5% for the first quarter 2015. Key drivers were an increase in stop loss benefit ratios back to normal ranges, lower mortality gains experience in income annuities, higher expenses related to growth initiatives and higher losses on hedge fund investments than in first quarter 2014. All segments reported lower pre-tax operating income in the first quarter 2015 compared to the prior year. Interest rate margins have remained generally intact and recent sales of employer medical stop loss, deferred and fixed index annuities continue to be strong while universal life sales continue to grow. Fitch expects Symetra's earnings will be negatively affected in a sustained low interest rate environment.
Symetra's balance sheet remains a key strength for the rating with very strong capitalization, moderate financial leverage and a high quality, liquid investment portfolio. Statutory capital of Symetra Life is considered very strong with an RBC ratio at 464% at March 31, 2015. Symetra Life has a small captive reinsurer in place to manage reserve financing of its universal life book of business. Financial leverage is considered moderate for the rating at 22.6% at the end of the first quarter 2015 and operating leverage low for the rating and exposure to capital market funding is not excessive.
Symetra's risky assets declined to 79% of total adjusted capital at year end 2014 from 91% at yearend 2013 and us below the life industry average of 87%. Symetra's bond portfolio has normally carried a greater than industry allocation of 'BBB' rated bonds and an average exposure to below investment grade bonds (BIGs). The company's investment portfolio has higher than average exposure to commercial mortgages than the life insurance industry as this asset class has grown to over 15.5% of invested assets. Mortgage credit quality is considered high and mortgage performance has been very good with 99.9% of mortgages were in good standing at Dec. 31, 2014.
QBE Accident & Health Expands Medical Stop Loss Underwriting Team
with Steve McFarland and Claudia Gonzales
"We are very happy and excited to have both Steve and Claudia join
QBE Accident & Health," said Steve Gransbury, President of QBE A&H.
"Steve's specialized knowledge and experience will contribute
greatly to the growth of our medical stop loss captive platform and
Claudia provides additional expertise and depth to our rapidly
expanding stop loss team."
QBE's North America operations are part of QBE Insurance Group Limited, one of the top 20 insurers and reinsurers worldwide. Headquartered in Sydney, Australia, QBE operates out of 38 countries around the globe, with a presence in every key insurance market. The North America operation, headquartered in New York, conducts business through various property and casualty insurance subsidiaries. QBE insurance companies are rated "A" (Excellent) by A.M. Best and "A+" by Standard & Poor's. Contact Phil Giles, Vice President -- Sales & Marketing, Accident & Health, at 910.420.8104, firstname.lastname@example.org and visit www.qbeah.com.
Health Catalyst Chief Clinical Officer Holly Rimmasch Recognized by Utah Business Magazine as a Top Woman Executive
MyHealthGuide Source: Health Catalyst, 5/21/2015, www.healthcatalyst.com
SALT LAKE CITY -- Health Catalyst, a leader in healthcare data warehousing and analytics, congratulated Executive Vice President and Chief Clinical Officer Holly Rimmasch on being named one of Utah's top woman executives by Utah Business.
In its May 2015 cover story, the magazine praised the award winners as "dynamic, influential leaders shaking up Utah's business scene." Among several hundred nominees, winners were selected for their contributions to the Utah business community, for their professional accomplishments, and for giving back to the community. Rimmasch will accept the 2015 "30 Women to Watch" award today in a ceremony at The Grand America Hotel in Salt Lake City.
"We congratulate Holly on this well-deserved honor," said Dan Burton, Chief Executive Officer of Health Catalyst. "She is a pioneer in clinical improvement initiatives whose expertise about the healthcare setting and healthcare operations has contributed to the health of people across Utah and beyond. We're lucky to have her on our team."
Rimmasch brings nearly 30 years of clinical and healthcare management experience to Health Catalyst, supporting its mission of eliminating waste and systematically standardizing best practices across US hospitals and health systems. She has spent the last 17 years pioneering systems for improving clinical care through implementation of clinical and operational best practices, most recently as an Assistant Vice President at Intermountain HealthCare responsible for Clinical Services.
In her three years as a senior executive at Health Catalyst, Rimmasch has been instrumental in driving the company's growth and maturing its product offerings. In particular, she has spearheaded the creation of Health Catalyst's Three Systems approach to performance improvement: a combination of 1) data warehousing and analytics technology, 2) organizational change management, and 3) the consistent integration of evidence-based best practices into everyday care delivery.
"I am extremely grateful to Utah Business for naming me one of Utah's Women to Watch, especially in light of the amazing work done by the other executives on the list," said Rimmasch. "To the extent that I've been successful, however, the credit really belongs to our extraordinary clients, whose commitment to making US healthcare a better, more efficient and cost-effective system for all Americans is truly something to watch."
A Utahn by birth, Rimmasch received a bachelor's of science from Brigham Young University and a master's of science from the University of Utah.
About Health Catalyst
Health Catalyst is a mission-driven data warehousing and analytics company that helps healthcare organizations of all sizes perform the clinical, financial, and operational reporting and analysis needed for population health and accountable care.Our proven enterprise data warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more than 50 million patients for organizations ranging from the largest US health system to forward-thinking physician practices. Visit www.healthcatalyst.com.
Lisa Olexy Elected to TPAAA Board of Directors
MyHealthGuide Source: Business Wire, 5/19/2015, www.tpaaa.org
MIAMI -- Lisa Olexy, Independent Living Systems Senior Vice President of Sales and Marketing, was elected to the Third Party Administrators Association of America (TPAAA) Board of Directors.
TPAAA advocates on behalf of Third Party Administrators (TPAs) to state legislators, regulators and others so that lawmakers know the role served by TPAs in the health care industry. TPAs provide important administrative functions to self-funded and managed care organizations such as benefit administration, provider contracting, and claims processing.
ILS offers TPA services to multiple health plans including Managed Long Term Care (MLTC), Medicare Advantage, Medicaid managed care, and commercial plans.
With more than 25 years of experience in health care sales, account management, and marketing, Olexy stated, "I am pleased to join the TPAAA Board of Directors and I am committed to working with the other Board members to advance the interests of TPA organizations to state and federal policymakers."
Olexy will participate in her first TPAAA board meeting on June 2, 2015 in Washington, D.C.
About Independent Living Systems
Independent Living Systems (ILS) is a Miami, FL-based health care company that operates a range of health care management services on behalf of health care plans that serve Medicare, Medicaid, dual eligible, and Special Needs members. ILS features a full continuum of services that enable millions of members to successfully transition through critical stages of episodic and long-term care. Visit ilshealthservices.com.
Third Party Administrators Association of America (TPAAA) is Louisville, KY-based organization with a Washington D.C. public affairs office that advocates for the advancement of state public policy and business interests for Third Party Administrators (TPAs) to foster choice, innovation, quality, and affordable healthcare delivery options for self-funded employers, Taft-Hartley and municipal health benefit plans nationwide. Visit www.tpaaa.org.
Symetra's Margaret Meister Named CFO of the Year
MyHealthGuide Source: Symetra, 5/7/2015, www.Symetra.com
BELLEVUE, WA -- Symetra, a national provider of employee benefits, annuities and life insurance, announced that the Puget Sound Business Journal has named Margaret Meister one of its 2015 CFO of the Year honorees. These annual awards recognize financial professionals in Washington State for exceptional financial stewardship and corporate leadership across eight categories, including nonprofit, private and public. Selections are based on the prior year's company performance; the executive's contributions for economic growth within the organization; and their leadership role in the larger business community. Ms. Meister is the recipient of the 2015 CFO Leadership Award.
"Margaret Meister is a prime example of the modern, multi-faceted CFO, whose role has evolved from a focus on managing a company's financials to leading key strategic aspects of a major multi-line corporation. She is a rare talent who possesses an uncanny combination of financial acumen, business judgment and outstanding leadership," said Tom Marra, president and CEO of Symetra Financial Corporation. "In 2014, Margaret's contributions to Symetra continued to span the breadth of the company and were felt deep within an organization seeking to grow into a national player in the insurance industry."
Ms. Meister joined Symetra in May 1988 as an actuarial student. In February 2006, she was appointed to her current position as executive vice president and chief financial officer of Symetra Financial Corporation and its insurance subsidiaries. Ms. Meister leads the company's financial operations and strategy, and serves as a liaison between the company and its board of directors, shareholders, rating agencies and analysts. She also serves as the chief risk officer, principal financial officer and principal accounting officer of Symetra and currently oversees Information Technology.
Ms. Meister holds a B.A. in Mathematics from Whitman College in Walla Walla, Washington, and is a Fellow of the Society of Actuaries. She currently serves on the board of directors of the United Way of King County.
This is the ninth year that the Puget Sound Business Journal has honored the financial super-strategists of Washington companies and organizations. Ms. Meister will be recognized along with the seven other category winners at the 2015 CFO of the Year Awards dinner at the Grand Hyatt in Seattle on June 4. For more information about the Puget Sound Business Journal's 2015 CFO of the Year Awards, please visit http://www.bizjournals.com/seattle/event/122981.
Symetra Financial Corporation (NYSE: SYA) is a diversified financial services company based in Bellevue, Washington. In business since 1957, Symetra provides employee benefits, annuities and life insurance through a national network of benefit consultants, financial institutions, and independent agents and advisors. Visit www.symetra.com.
Sales Manager, Employer Programs
Interested candidates should send resume to Ali Duerr, Marketing Manager, PartnerRe America Insurance Company, at email@example.com.
About PartnerRe Ltd.
HIIG Elite Underwriting has an Opening for a Stop Loss Health
Insurance Sales Executive (Arizona)
Essential Requirements for Education and/or Experience
HIIG Elite offers
1. A competitive base salary with performance based commissions
HIIG Elite Underwriting Has an Immediate Opening for Clinical Risk Manager (RN Required)
Houston International Insurance Group (HIIG), 5/22/2015,
Essential Requirements for Education and/or Experience
Specialized Knowledge/Beneficial Skills and Experience
HIIG Elite offers
1. A competitive base salary with performance based commissions
Considerations when Evaluating Vendor Solutions for Electronic
Adoption and Compliance
Do your homework – Multi vs. Single Source Solutions
Some vendors appear to offer everything you need. However, when more closely examined, these vendors specialize in only one payment resolution method. As an example, there are many electronic vendors offering a virtual card driven solution. EFT capabilities, which deliver the compliance you seek, are often limited with insignificant levels of providers actually enrolled to be paid in this manner. This creates risk and may introduce new complications in your workflow as often time the burden will fall back upon the payer to engage and enroll providers or seek additional vendors to provide the needed EFT adoption.
These suppliers seem attractive at first because they offer a lucrative revenue-sharing option, generated from the virtual card. However, the virtual card is only a single piece of evaluating a sustainable long-term solution. When conducting your vendor evaluation, important considerations should be:
Payers evaluating these solutions should also pay close attention to the implementation plan and payment reconciliation workflows. Many times multi-source solutions issue and settle payments from three separate sources. Your internal workflow can become cumbersome and require additional support to reconcile all of your payments. Be sure to request a documented Implementation Plan with timelines and resource expectations. You can avoid a failed or stalled implementation by using a well-defined implementation plan to set proper expectations. However, be aware of indicators that you are implementing multiple payment processes with a single vendor. If the vendor issues and settles payments from different sources based on payment modality, daily workflows and processes may become more complex from your current state.
While quality multi-source products can produce beneficial results, expenses can climb if you have to add two or more multi-source vendors that each solve a single need. The payer may feel they need to reinvent themselves in order to accommodate each vendor's separate methodologies. Be confident that you do not need to implement a short-term or incomplete solution. A multi-source solution usually cannot manage all of your payments without complicating your daily operations.
Single Source Solutions
Single Source solution vendors can manage all of your payments and offer the payer a steady reconciliation process. A single source solution will preclude a payer from interfacing with multiple vendors, banks or other interfaces of the payment stream. Effective solutions should include important features such as the ability to link the real-time payment status to the adjudication system detail and originating funding event. This simply means that a payer can locate all relevant details for all payments through a single data source including images of cancelled checks.
Additional important distinctions should focus on a long-term vision of migrating providers to electronic payments without exclusive dependence upon a virtual card. Payers should ask very specific questions about the number of providers enrolled for EFT and for specifics on their population of Provider Tax ID's. If the vendor cannot confirm a match of 25% or greater, the program will very likely achieve substandard results. ERA capabilities should also be properly vetted in this discussion. Confirm the vendor's capabilities to produce a compliant 835 from your current extract or print file. Ask specific questions about their experience with different adjudication systems, current production volumes, and if any crosswalk or tables will be required.
Any vendor under consideration should have well-documented implementation plans and weekly accountability calls. Newly implemented payers will be a very important reference point to confirm associated implementation timelines. The implementation team should have the ability to manage and lead the customer through a fully customized implementation that accounts for unique customers or plan designs. The result of these efforts is a refined, streamlined daily operation and workflow.
A quality decision under a single source platform should include:
Consider Vulnerabilities and Security Risks
A critical step in the evaluation process is security. In healthcare payment processing there are many possible exposures such as private health information and banking transaction details. In your evaluation, ask how personal health information is protected and how security breaches and financial loss are avoided.
Established vendors are comfortable providing documented support of their security infrastructure and software protocols along with backup, failure and redundancy programs. Further, they can offer a voluntary third party audit of their organization proving their claims. This level of scrutiny compliance with not only healthcare regulatory procedures such as HIPAA and ACA, but financial transactions are protected as well through FDIC insured payments and Payment Card Industry Data Security Standards (PCI DSS) compliance.
With the aforementioned mandate and operating rules, third party payment services have quickly become a growth industry with many new entrants. Proper due diligence should include specific questions about a vendors growth and scalability. Companies committed for the long-term should conduct regular assessments and ensure that growth is aligned with infrastructure capabilities.
In a world where Fortune 100 companies are subject to data breaches, it is imperative to understand what measures a vendor takes to protect your data. With user interfaces and provider portals, there are often many access points that expose a company to potential breaches. Vulnerability testing and regular static scans are indicators that your vendor is taking the necessary precautionary measure.
If the vendor uses a series of vendors themselves to provide their services, be cautious that all parties maintain the same level of security standards. Distinct lines of responsibility and liability should be clearly defined in contracts.
Timeline for achieving compliance
Achieving compliance quickly can be a real possibility. Once the due diligence process is complete and you have narrowed your vendor selection, you can verify your selections are CORE certified if you have not already by going to http://corecertification.caqh.org/CORE_organizations. Each health plan can begin achieving compliance on day one of production with a CORE Phase III Certified vendor.
A fully engaged payer and vendor can complete an implementation in 6-7 weeks. If your due diligence indicates that your vendor selection cannot perform within these parameters with validated references, this may be an indication to consider other options.
Electronic payment solutions range in quality and effectiveness. To
ensure your organization partners with a vendor that can deliver the
capabilities your organization needs ask the following questions: Do
they provide a single source solution to handle all of my payments
seamlessly? Can they provide documented support of their security
infrastructure and programs? Does their solution allow my company to
achieve compliance quickly? If the answer to each of these questions
is yes, then you have found a quality vendor.
About the Authors
Tom Davis is the Executive Vice President of Business Development and Jennifer Plake is the Strategic Sales Associate at ECHO Health, Inc., a leading provider of electronic healthcare payment solutions. Serving more than 50,000 ERISA health plans and fully insured groups, ECHO processes more than $10 billion in payments annually to providers and members through industry-leading payers. Founded in 1997, ECHO is a privately held company located in Westlake, Ohio. Visit www.echohealthinc.com.
Captivating Options in Healthcare Coverage
MyHealthGuide Source: Risk Solutions Captive, Inc. (RSC), 5/20/2015, www.risksolutionscaptive.com
For most businesses today, choosing a healthcare coverage option is a challenging and daunting task. While business owners are faced with the difficulties of managing their balance sheet, the reality is that health insurance is an expensive cost that can quickly drain hard-earned margins.
Fully insured plans are the most widely known option, yet recent legislation has mandated benefits, which has driven costs to rise. As most agents know, it is not unusual for a group to face a 5-10% increase per year on a good year. The reason that many groups go with fully insured plans is due to their perception that the risk of self-funding options is not worth the savings that these groups can achieve each year. "Perception" is the operable word here, as today's marketplace has additional options designed to fit small to medium employers with healthcare solutions that were previously unavailable.
The perception of fully insured plan safety prevents organizations from self-funding, which presents opportunities for improved cash flow, flexible benefit designs, avoidance of state mandates and even tax savings. Captives are perfect examples of the trends emerging as healthcare options. While plans like these have been available to some of America's largest employers for years, healthcare captive plans have just recently become available for small to mid-sized employers. This provides new options in cost containment for markets previously locked out from these products.
The Captive Advantage
1The captive model was founded in the 1950's for mining companies in Ohio. While the term "captive" became synonymous with these types of plans (due to the captive mining employees who were being covered), today's captive plans look much different. The objective of controlling an organization's medical trend remains at the core of captive health plans.
One particular captive model that continues to grow in popularity across the country is best described as a "funnel." The top tier is where all the claims and expenses go into the process. The group pays the first 33% of the funnel's expenses. As you proceed farther down the funnel, the expense goes down, the more parties become engaged in sharing the expenses.
For the next 33% of the expenses, the third party administrator (TPA) who pays the claims and processes the membership pays for this cost. This ensures that the group and the TPA have a fiduciary responsibility to proactively address any claims problems and promote healthy living for the group. A reinsurance carrier covers the final third (33%). This is for your claims over a certain catastrophic amount. This model allows all parties to have a level of exposure so that the management of healthcare expenses by the employer, third party administrator and reinsurance carrier all collectively benefit the employer.
Based on organizations such as the Self Insurance Association of America (SIIA), captives and self-funding are the venues of choice for more than 90% of the Fortune 500 plans in America. This goes to show that large employers have long known about the savings that they can achieve by offering a captive health plan to their employees. The freedom to customize benefit options, control healthcare spending and meet all state and federal guidelines has caused this option to become attractive to many more organizations today. Small, mid-sized and large businesses each find compelling advantages to offer captive plans – primary advantage being the cost savings.
Can a Small or Mid-Sized Employer be on a Captive Plan?
While a strong balance sheet and a willingness to manage costs are two defining characteristics of a captive inclined organization, today support is available to help a company successfully manage their captive plan more than ever before. By partnering with a captive administrator, one is guided through the steps necessary to drive a successful captive implementation and maintenance. The partnership between the captive administrator and the small to mid-sized employer enables any organization to fully comply with the Affordable Care Act regulations. This is one of the key reasons that the use of captive plans has grown rather significantly in the past 2-3 years.
With healthcare today accounting for a sizeable portion of a business' operating expense, employers are faced with a similar problem that the mining companies of the 1950's experienced. There has to be a way for companies to offer affordable health coverage without risking their financial earnings on one ill-fated injury or illness. The selection of a captive plan is the answer, no matter the business size.
Insurance has changed significantly over the past three years, primarily due to the Affordable Care Act (ACA). What many employers seem to forget though, is that the movement to health incentives and wellness initiatives actually began years before ACA was passed. In the pre-ACA environment, this was largely due to large insurance carriers searching for ways to maximize their profits by reducing loss ratios.
With the lack of incentive to do this today, mainly due to defined Medical Loss Ratio's, the self-funding industry is the main proponent of enhancing the health of one's employees. However, the trend of incentivizing healthier employees extends beyond the loss ratios of a company; employee health has also been shown to enhance productivity, satisfaction and retention.
Employers of all sizes have more choices for coverage than ever before. Not all models are appropriate for every business, yet, with the emergence of small to mid-sized employers embracing the captive model, a new benchmark in healthcare coverage has emerged.
About Risk Solutions Captive
Risk Solutions Captive, Inc. (RSC) provides innovative solutions for companies with 50 or more employees in the self-funded arena. RSC's partnership with Health Cost Solutions (HCS), the TPA, provides the foundation for RSC with a variety of services including claims payment, cost containment, billing, reporting and COBRA services. By partnering with a highly rated reinsurance carrier and Health Cost Solutions, Risk Solutions Captive offers risk protection from high-dollar claims exposure and the highest quality TPA services. Visit www.risksolutionscaptive.com.
1 Mitchell, D. (2013) Captive Carriers in Healthcare 101. American Society of Healthcare Risk Management. October, 2012
TABA advises that the Texas House
Committee on Investments and Financial services will discuss a
prohibiting payments of any health care bill with a virtual payment card.
HCAA and TABA urge to members of the self-funded community to voice
opposition to this restriction.
The Texas Association of Benefit Administrators (TABA) serves the business needs of owners and executives of third party administration companies engaged in providing services in Texas and to further the advancement of the third party benefit administrators profession.. Visit www.tabatpa.org.
HCAA was formed in 1980 as the Independent Administrators Association, a California-based not-for-profit that acted as a legislative and regulatory advisory group for third party administrators and related service providers. Following the passage of ERISA and similar laws, third party administrators needed a voice in Washington as well as educational opportunities with leading experts in the industry. Visit www.hcaa.org.
Third Circuit Adopts Catalyst Theory in ERISA Cases for Attorney Fee Awards and Has 'Chilling Effect' on Settlement of ERISA Claims
MyHealthGuide Source: Joshua Bachrach, 5/14/2015, Wilson Elser
Case: Templin v. Independence Blue Cross, No. 13-4493 (3d Cir. May 8, 2015) Court's Ruling
The Third Circuit failed to recognize the chilling effect its ruling will likely have on settlement of ERISA claims once a lawsuit is filed. Also lost on the court is the potential increase in lawsuits involving questionable ERISA claims by attorneys hoping to secure a nominal settlement and then demand fees as a result.
Under ERISA, "the court in its discretion may allow a reasonable attorney's fee and costs of action to either party." The discretion of a court to award fees is not unfettered. Reviewing the language in the ERISA statute, the Supreme Court in Hardt v. Reliance Standard Life Ins. Co., 560 U.S. 242 (2010), held that a party does not need to be a prevailing party to be eligible for an award of fees. Still, a party must achieve "some degree of success on the merits." To satisfy this requirement, a claimant must achieve more than just a "purely procedural victory."
In the above Templin case, the Third Circuit opened the door to fee recoveries in ERISA cases in a way not contemplated by Hardt. The court decided that a party can achieve success on the merits without any judicial action. In Templin, the court decided that the defendants' voluntary payment of interest was sufficient to make the claimants eligible for attorney fees under Hardt.
By way of background, the plaintiffs in Hardt brought claims under ERISA based on the refusal of the defendants-insurers to pay claims for certain medical products. After the lawsuit was filed and the court denied a motion to dismiss based on failure to exhaust, the defendants approved the claims and the court dismissed the complaint. Both parties then filed motions for attorney fees, which were denied. In an earlier appeal, the Third Circuit affirmed the denial of fees but concluded that the case had to be remanded to the lower court to determine whether the claimants were entitled to interest on the delayed payment of benefits.
On remand, the claimants sought interest between $1.5 and $1.8 million. Eventually the parties settled the interest claim for only $68,000. Afterward, the claimants sought attorney fees of nearly $350,000. The district court denied the motion for fees based on its conclusion that the question of whether the claimants were entitled to interest "was settled among the parties outside the courtroom and without a judgment from the Court." The claimants then appealed, arguing that they were entitled to fees under a catalyst theory.
The Third Circuit agreed with the claimants that they were eligible for fees because the filing of the lawsuit was the catalyst to their recovery of interest. The court distinguished the Supreme Court decision in Buckhannon Board & Care Home v. West Virginia Dept. of Health and Human Services, 532 U.S. 598 (2001), which rejected the catalyst theory under a different fee-shifting statute. The court explained that the fee statute at issue in Buckhannon included a prevailing party requirement that is not included in the ERISA statute. On this basis, the court refused to apply Buckhannon. Accordingly, the catalyst theory is available in ERISA cases.
According to the Third Circuit in Templin, all "that is necessary is that litigation activity pressured a defendant to settle or render to a plaintiff the requested relief." The court, however, said that to be eligible for fees, the litigation result must be "non-trivial, and more than a procedural victory…." Under this standard, the court concluded that the claimants were eligible for an award of attorney fees because the settlement for $68,000 in interest was a "substantive victory."
It is difficult to reconcile the Third Circuit's holding in Templin with the decision in Hardt. In Hardt the defendant voluntarily paid the benefits claimed by the ERISA plan participant but only after the district court issued an order denying the defendant's motion for summary judgment and remanding the claim for further review. The district court also made favorable comments about the claimant's eligibility and said that if the defendant did not make its remand decision within the time included in the order, judgment would automatically be entered for the claimant.
The Supreme Court concluded that Hardt achieved some degree of success on the merits and was eligible for an award of fees. The conclusion was not based on the voluntary payment of benefits, however. It was not even based on the remand alone. The Court recognized that there was more than just a remand. In addition to the remand, the district court made comments favorable to the claimant regarding the merits of her claim. As noted above, the district court also stated that judgment would automatically be entered in favor of the claimant if the remand decision were not made on time. Under these facts, the Supreme Court concluded that Hardt achieved more than just a procedural victory. The claimant achieved some degree of success on the merits. The Court reserved for another day the question of whether a remand "without more" is enough to be eligible for fees.
Nowhere in Hardt did the Supreme Court even suggest that a defendant's voluntary payment of benefits, a fact present in the case, is sufficient to become eligible for fees. To the contrary, the Court described in detail the judicial actions taken by the district court, which supported the award of fees to Hardt. If a "purely procedural" victory is not enough under Hardt, why should a claimant who does not even achieve that be permitted to recover fees under the ERISA statute as permitted in Templin?
While Buckhannon involved a fee claim under a different federal fee-shifting statute that requires prevailing party status, there is language in the decision that seemingly applies equally to the ERISA statute. For example, the Buckhannon court held that a "defendant's voluntary change in conduct" while providing the relief requested "lacks the necessary judicial imprimatur on the change." Absent any "judicial imprimatur," an ERISA litigant also does not achieve any "success on the merits." Such success necessarily requires some form of action by a court, which was lacking in Templin.
There is additional language in Buckhannon that raises doubts as to the applicability of the catalyst theory in ERISA cases. The Court recognized "the disincentive that the 'catalyst theory' may have upon a defendant's decision to voluntarily change its conduct, conduct that may not be illegal." As the Court explained, the "defendants' potential liability for fees in this kind of litigation can be as significant as, and sometimes even more significant than, their potential liability on the merits and the possibility of being assessed attorney's fees may well deter a defendant from altering its conduct."
The Third Circuit failed to recognize the chilling effect its ruling will likely have on settlement of ERISA claims once a lawsuit is filed. Also lost on the court is the potential increase in lawsuits involving questionable ERISA claims by attorneys hoping to secure a nominal settlement and then demand fees as a result.
A primary goal of ERISA was to provide a forum for employers and employees to resolve disputes over benefits inexpensively and expeditiously. Perry v. Simplicity Engineering, 900 F.2d 963, 966-67 (6th Cir.1990). Recognition of the catalyst theory in ERISA cases can only prolong the resolution of disputes as it provides a disincentive to settlement. In turn, this will result in more-expensive litigation. Hopefully, the Third Circuit's position in Templin will not be followed in other circuits
About Wilson Elser
Wilson Elser helps individuals and organizations transcend challenges and realize goals by offering an optimal balance of legal excellence and bottom-line value. Nearly 800 attorneys strong, our firm serves clients of all sizes, across multiple industries and around the world. Wilson Elser has 27 strategically located offices in the United States, another in London and several European affiliates. This depth and scale has made us one of the nation's most influential law firms, ranked in the Am Law 200 and in the top 50 of the National Law Journal 350. Visit www.wilsonelser.com/about.
Colonoscopy Recommended at Age 40 for High-Risk Americans
MyHealthGuide Source: Meng-Han Tsai, MHA; Sudha Xirasagar, PhD, MBBS; Yi-Jhen Li, PhD; Piet C. de Groen, MD, 5/21/2015, Center for Disease Control and Prevention and National Institute of Health / MedlinePlus
Colonoscopy screening reduces colorectal cancer (CRC) incidence
and mortality. CRC screening is recommended at age 50 for
average-risk people. Screening of first-degree relatives of CRC
patients is recommended to begin at age 40 or 10 years before the
age at diagnosis of the youngest relative diagnosed with CRC. CRC
incidence has increased recently among younger Americans while it
has declined among older Americans. The objective of this study was
to determine whether first-degree relatives of CRC patients are
being screened according to recommended guidelines.
Researchers conclude that despite a 5-fold increase in
colonoscopy screening rates since 2005, rates among first-degree
relatives younger than the conventional screening age have lagged.
Screening promotion targeted to this group may halt the recent
rising trend of CRC among younger Americans.
Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 4/4/2015)
Editor's Note: The following is a recurring article. This Newsletter is often asked by readers for a list of medical stop-loss providers and their respective premiums. Below the first of a recurring article that attempts to lists stop-loss providers and annual premiums. Sources includes press releases, AM Best reports, conference presentations and more.
Other stop-loss leaders include the following list. However, we await reader response providing stop-loss premium volume (and additional carriers) so that each could be added to the table above.
Stop-loss Premium Volume is not the Whole Story
Industry executives question the purpose of a chart reporting only stop-loss premium without additional information such as:
Reader response and correction is encouraged. Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com.
The Value of Self-Funding
MyHealthGuide Source: The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, www.SIEFOnline.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.
June 3-5, 2015
June 15-17, 2015
July 15-17, 2015
MCIA Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA). Features 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 in Whitefish, MT. Sponsors: Shane Byars at 866/388-6242, or via e-mail at firstname.lastname@example.org. Contact email@example.com and visit www.mtcaptives.org
September 14-16, 2015
September 28-30, 2015
October 18-20, 2015
The health care sessions are part of a larger educational program that includes nearly 40 general and breakout sessions related to the broader self-insurance marketplace. This top-notch educational program will be supplemented by the industry's largest exhibit hall and incredible networking opportunities throughout the event. Marriott Marquis, Washington, DC. Call 800-851-7789 and visit www.SIIA.org
February 9-11, 2016
March 30-April 1, 2016
July 13-15, 2016
October 17-19, 2016
February 8-10, 2017
March 15-17, 2017
September 13-15, 2017