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News for the Self-Funded Community

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General & Company News

People News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures

General & Company News

AMPS Acquires Claims Delegate Services

MyHealthGuide Source: Advanced Medical Pricing Solutions (AMPS), 12/13/2014,

Advanced Medical Pricing Solutions (AMPS) announced their acquisition of Claims Delegate Services (CDS), Inc.

"We are pleased to report our acquisition of CDS which was completed late last night, said Mike Dendy, President and CEO of AMPS. This is the perfect ending to a year in which our growth rate topped 60% and our national footprint expanded dramatically, Dendy continued.

"Along with CDS, AMPS launched our Reference Based Reimbursement (RBR) program three years ago as an alternative to the value eroding PPO networks", said Dendy. From day one of implementation our clients have seen dramatic reductions in their healthcare spending as we eliminate the partnership for overpayments that the PPOs and many of the nations hospitals have created together, continued Dendy.

"Our clients are often speechless when we document what they are paying for hospital services after what they believe are the PPOs discounts, said Jim Delaney, Chief Operating Officer of AMPS". On average we find payment levels of over 260% of Medicare and many times we find post PPO payments greater than 400% of Medicare continued Delaney. "The problem for employers is that they don't know what they are paying for services and if they ask the PPO network to benchmark what they are paying they just refuse citing proprietary contracts and relationships", continued Delaney.

CDS, which is currently based in Boca Raton, Florida will be moving operations to Atlanta, Georgia in early 2015. Rick Hirsch, the current CEO of Claims Delegate Services will remain with the company as President and Chief Legal Council of the organization reporting to Mike Dendy, AMPS' CEO/President.

About AMPS

AMPS has become the preeminent supplier of healthcare claim review and verification services over the past eight years. Our charge of excellence has now expanded to wellness, dependent verifications, and progressive re-pricing models. Our direction is to bring the same level of professionalism and leadership within these segments of cost management that we have delivered previously with our established claim services.  Visit


H.H.C. Group Launches Cost Charge Ratio Reference Based Pricing Service

MyHealthGuide Source: H.H.C. Group, 12/12/2014,

H.H.C Group, a leading healthcare insurance consulting company, today announced the launch of its Cost Charge Ratio Based Pricing Service, designed to help payors of all sizes reign in ever increasing provider related costs.

"PPO discounts have been only partially successful in controlling spiraling provider costs. Many larger insurers have already made the switch to Reference Based Pricing or are considering doing so, putting all who compete with them at a serious disadvantage", said Dr. Bruce Roffé, President and CEO of H.H.C Group.

"Like our Medicare Based Pricing Product, Cost Charge Ratio Based Pricing offers a number of advantages over pricing based on a percentage off billed charges alone. Both eliminate excess charges due to providers artificially inflating their prices for services delivered. They also ensure similar payment for the same or similar services", stated Dr. Roffé.

For Cost Charge Ratio or Medicare Based Pricing to be successfully implemented, payors will need to garner provider acceptance and minimize balance billing. Providers will have to be willing to accept prompt and reasonable payment as payment in full for their services. H.H.C Group also offers a service to secure agreements with key providers.

It will take time to convert to Cost Charge Ratio or Medicare/DRG Based Pricing. However, those presently paying based on DRGs can start using H.H.C. Group's DRG Validation immediately to ensure that claims are being properly coded and payment is appropriate for the services provided. As Medicare/Medicaid Recovery Audit Contractor audits have shown, miscoding and up-coding errors are extensive and the potential for savings huge.

About H.H.C. Group

H.H.C. Group is a leading national health insurance consulting company providing a wide range of cost containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. H.H.C. Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service.

H.H.C. Group's services include Claims Negotiation, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claim Repricing, Claims Editing, Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, Predictive Modeling, Disease Management and Pharmacy Consulting. H.H.C. Group is one of forty-six URAC accredited IROs.  Contact Bob Serber at, 301-963-0762 ext. 163 and visit


Auxiant Continues Indiana Expansion

MyHealthGuide Source: Auxiant, 12/10/2014,

Auxiant, the largest privately owned TPA for self-funded benefits plans located in Wisconsin, and the longest existing TPA in Iowa, announced the expansion of its TPA services to the state of Indiana in late 2013.

This expansion has produced immediate results, and Auxiant now has expanded its client base to include employer groups from across the state of Indiana. Auxiant's longstanding focus and expertise in Third Party Administration and unique, forward-looking approach are expected to continue to drive rapid growth throughout the state in 2015. Using a variety of cost management tools, Auxiant health plans are consistently beating the state and national average. One of the key components of Auxiant's success has been an innovative product called 'FocusHealth'. FocusHealth is now in its 4th year of growth, and is producing impressive results across the Midwest.

How FocusHealth Works:

FocusHealth's methodology combines the most accurate and reliable cost and quality data for inpatient and outpatient hospital procedures -- even hospital comparisons. FocusHealth then combines the cost and quality scores to provide a composite value score. Creative plan designs incentivize members to use the highest value facilities.

About Auxiant

Auxiant is an Independent Third Party Administrator (TPA) of self-funded benefit plans, specializing in customization, technological tools for clients, cost-control and health management. Auxiant is known for its innovation and technology, constantly evolving to meet the needs of its clients.

From their offices located in Cedar Rapids, IA, Madison, WI, and Milwaukee WI, Auxiant provides administration for over 245 clients covering in excess of 95,000 member lives. Auxiant works with a very diverse group of clients, all having customized benefit plans. Each client is given unmatched personalized service by a dedicated service team, and Auxiant's strength in the marketplace provides a powerful advantage to any self-funded employer group.  Contact John Holt, Auxiant National Sales Executive for Indiana at 1-800-682-0795, and visit


Livongo Health™ Signs Iron Mountain Self-Funded Employer to Implement Livongo Ecosystem to Improve Lives of Employees with Diabetes

MyHealthGuide Source: Livongo Health™ via PRNewswire, 12/12/2014,

PALO ALTO, CA -- Livongo Health™, a consumer digital health company that is focused on using technology to empower people with chronic conditions to live better, announced an agreement with Iron Mountain Incorporated. They wanted to improve the health and productivity of their employees with diabetes while reducing the cost of care. Today, this cost ranges from $8,000-$20,000 per person per year and can represent up to 25% of an employer's total health care costs.

Livongo for Diabetes™ provides an end-to-end ecosystem that empowers people with chronic diseases to live better, starting with diabetes. It starts with a smart cloud that captures information from a variety of devices (numbers, behavior, activity), analyzes it in combination with other data about the individual and provides that information in real time to the complete care team -- the person with diabetes, their care team, and their care managers. Today, for diabetes, it starts with the industry's first interactive, cellular-enabled blood glucose meter.

Iron Mountain, a leading provider of storage and information management services headquartered in Boston, MA, knew they needed to find a better way to keep their employees healthy while containing rapidly rising healthcare costs. They spend nearly $13,000 per year on each of their employees with diabetes.

"Livongo Health provides the perfect marriage of  technology and high touch," said Director of Benefits Strategy, Scott Kirschner. "With such a large employee population, it's incumbent on us to provide the very best care available to help them maintain a healthy lifestyle. We are convinced that their unique approach will have a dramatic impact on both the health of our employees and the cost of their care."

"This innovation company recognized the need to do something different and have embraced Livongo's approach to disease management. Livongo brings the most powerful technology and real-time data available today so people with diabetes can focus on their life, not their disease," said Glen Tullman, Chief Executive Officer of Livongo Health™. "We're redefining the experience for people with chronic diseases and also the way leading employers can support their workforce."

Iron Mountain will launch Livongo for Diabetes™ to their employees in the next 4 weeks.

About Livongo Health

Livongo Health™ is reinventing the way people manage chronic conditions, beginning with diabetes. We are focused on improving the experience for people with diabetes, the people who care for them (family, friends, physicians), and the people who pay for their care. By offering the right information, tools and support, at the right time, we empower people with diabetes to live better and improve their health while reducing the cost of care. Contact Catherine Riedel at, 312.209.0250 and visit


Bravo Wellness Solutions Receive Praise

MyHealthGuide Source: Bravo Wellness, 12/9/2014,

Cleveland, OH -- Bravo Wellness, the leader in outcomes-based incentives, is pleased to announce that several of its clients and partners have been named 2014 IHC Superstars. The Institute for HealthCare Consumerism (IHC) Superstar awards were created to recognize those individuals who go above and beyond in executing innovative health and benefit management programs or who provide those solutions to organizations.

Congratulations to Dennis Clark--Valeo, Chad Thies--Union Bank & Trust, Charlie Leatham--Hays Companies, and Kent Grathwohl--Group Associates (currently with Gallagher Benefit Services).

"We've been humbled with many great accolades for our company growth and success, but there's nothing more gratifying than seeing our clients and business partners earn recognition for the successful impact their wellness programs are having," said Jim Pshock, Bravo Wellness founder and CEO. "It's a true honor to be associated with these winners and to be a part of their award-winning strategies."

Dennis Clark, U.S. Human Resource Director at Valeo, Most Innovative Benefit Plan Design & Implementation Award. Dennis and his team's focus on reducing healthcare cost trends has been a tremendous success. Implementing outcomes-based wellness, along with frequent communication to employees and the availability of tools for health improvement, has helped drive 97% participation. Another Valeo business unit of similar size and demographics was not offered the wellness plan, allowing for the development of a natural control group. The difference was an 11% (control group) vs. a 2.5% claims cost trend over the five year period they've been working with Bravo! The participating population is slowing and reversing the national trends in obesity, elevated blood pressure, and nicotine usage.

Chad Thies, First Vice President of Human Resources at Union Bank & Trust, Most Effective Employee Communication & Education Award. UBT has created an array of unique benefits in the pursuit of associates' optimal health. And because of this pursuit, these benefits are made available to all employees, not just to those on the health plan. In addition to onsite health screenings and flu vaccinations, they hold educational meetings, provide access to free fitness memberships, health coaches, resource materials, and even offer free, healthy meals. They also created a Wellness Passport booklet, containing important information and resources for participants to utilize as they log their progress and personal journeys towards health.

Charlie Leatham, Vice President at Hays Companies, Most Innovative Partner/Consultant Award. Charlie recognizes the value of outcomes-based incentive programs and the impact they can have on employees' lives. He has helped multiple clients find success with these programs and understands the unique challenges each face in the delivery of their programs to employees. With his ability to naturally align the HR and benefits teams' goals with solutions that deliver results, Charlie works strategically with clients to meet their wellness needs and increase engagement towards good health.

Kent Grathwohl, Vice President at Group Associates, Most Innovative Broker Award. Kent has been a pioneer in introducing biometric-based wellness programs to his clients, guiding them to wellness solutions that are proven to maintain or even reduce corporate costs. Staying current on innovative and cutting edge applications in wellness has allowed Kent to provide unsurpassed support to his clients. With a strong understanding of, and involvement in his clients' philosophies, Kent is able to bring wellness initiatives that best fit each culture and effectively work for all employees.

About Bravo Wellness

Bravo Wellness has been a disruptive force in the wellness industry since its inception in 2008. Bravo pioneered the outcomes-based wellness incentive space and carefully designs compliant incentives that result in unprecedented engagement levels. Bravo's case studies prove and demonstrate sustained health improvement and reduced claims spending--all while equipping individuals to make better choices and providing thoughtful alternatives to those for whom special exceptions are warranted. With roots in data management, compliance and technology, Bravo recognizes that it's rarely the lack of activities that makes a program unsuccessful, it's often the lack of motivation and engagement--a problem that can be solved. Call 877.662.7286 and visit


Health Catalyst Collaborates with Microsoft on Data Warehouse and Analytics for Healthcare Industry

MyHealthGuide Source: Health Catalyst, 12/11/2014,

SALT LAKE CITY -- Health Catalyst announced its work with Microsoft Corp. to collaborate closely and deploy industry-leading data warehouse and analytics solutions for the healthcare industry.

Collaboration will be centered around Microsoft's Analytics Platform System (APS), which brings together SQL Server and Hadoop data into a pre-built appliance, integrated with Health Catalyst's Late-Binding™ Data Warehouse and Analytics Platform, a revolutionary approach to managing healthcare data across the continuum of care. The Health Catalyst Enterprise Data Warehousing (EDW) and Healthcare Analytics platform has been designed specifically for today's - and tomorrow's - highly complex and dynamic healthcare data environment. Microsoft SQL Server and APS, with its flexibility and scalability, is integral to Health Catalyst's mission to help its customers transform healthcare nationwide.

"Health Catalyst is a leader in developing data warehouse and analytics applications to help healthcare organizations achieve better clinical outcomes and research, in less time and for lower costs. There are few other companies in this highly competitive space that come close to its results," said Bill Hawkins, director of Health and Life Sciences Partners, Microsoft. "With initiatives such as population health management and accountable care continuing to grow in importance, the timing is right. Health Catalyst offers the type of disruptive thinking and deep industry knowledge that fits Microsoft's vision for the healthcare industry."

The collaboration encompasses several solutions over the short-term, mid-range and long-term, including:

  • Deploying and optimizing Microsoft's parallel data warehouse architecture (APS) at one of Health Catalyst's largest client organizations
  • Collaborating on the implementation of Health Catalyst's predictive models, geospatial analytics and natural language processing to assist with population health management (PHM) to improve clinician interactions with technology
  • Extending the Health Catalyst Late-Binding architecture and using PolyBase to combine SQL Server and Microsoft's Hadoop-based platform
  • Deploying Health Catalyst's de-identified comparative analytics platform, CAFÉ, to Microsoft Azure
  • Working together to enhance Atlas, Health Catalyst's proprietary metadata repository, its white space data entry tool IDEA and its Source Mart Designer, all of which are integrated with the SQL Server product line

Unlike traditional "early-binding" EDWs, which typically require up to 18 months and longer to begin delivering value, Health Catalyst's Late-Binding platform offers rapid time-to-value - often within a few months, if not weeks, according to the January, 2014 report Healthcare Analytics: Making Sense of the Puzzle Pieces by the respected healthcare research firm KLAS. Rather than binding source data to schemas, business rules and vocabulary when that data is first streamed into the data warehouse (as happens with typical EDWs), data in a Health Catalyst data warehouse is bound as it is needed by the analytic use case. This innovative design ensures that the data retains its original, unchanged and granular form, allowing the data to be constantly repurposed to support a multitude of use cases, providing the flexibility required in an industry where new uses cases and new data sources are constantly being defined.

"Our early bet to base our Late-Binding architecture on SQL Server has played out very well. Microsoft has achieved for data warehousing the same thing that we've come to expect from their office productivity suite - incredibly well-integrated, affordable, and highly capable tools," said Dale Sanders, senior vice president of strategy, Health Catalyst. "From the desktop to the database, the Microsoft SQL Server and APS stack is by far the most efficient, best-integrated and most cost-effective platform in the analytics market today, helping our customers deliver the most cost effective, highest quality healthcare."

Sanders added: "Microsoft's scalability has also been clearly demonstrated in a variety of situations, where large organizations manage hundreds of terabytes and tens of thousands of queries per day in their Microsoft-based data warehouses. Microsoft's PolyBase platform also offers a seamless transition from the world of SQL to the Big Data world of Hadoop, when the scale and data content in our client sites call for that. We have a very ambitious agenda and are excited to formalize our collaboration with Microsoft and bring the depth and breadth of their expertise to our clients."

About Health Catalyst

HeaHealth 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 30 million patients for organizations ranging from the largest US health system to forward-thinking physician practices. Faster and more agile than data warehouses from other industries, the Health Catalyst Late-Binding™ EDW has been heralded by KLAS as a "newer and more effective way to approach EDW." Visit


HCAA Announces 2015 Executive Forum - 'Spotlight on Self-Funding'

MyHealthGuide Source: The Health Care Administrators Association (HCAA), 12/10/2014,

MINNEAPOLIS, MN -- The Health Care Administrators Association (HCAA), a leader in advocacy, education and networking for the self-funding industry, announces its 2015 Executive Forum to be held February 9-11, 2015 at the Encore at Wynn Las Vegas.

The two-and-a-half-day event will feature educational sessions on a variety of pressing self-funding topics, including the keynote session from Senator William Frist, MD discussing "A Physician-Senator's Look into the Crystal Ball of Healthcare Reform." From Appeals Court rulings impacting exchanges, to employer mandates, to changes in the reimbursement system, Senator Frist has been in the forefront of those willing to address the controversial decisions and to propose solutions. This session will offer insight on what will happen to impact the self-funding industry over the next six months, next five years and beyond.

"Many new changes and challenges are on the horizon for healthcare that place the self-funding industry at the forefront of opportunity," said Kevin Larson, president of HCAA and president of Employee Benefit Management Services Inc. "At this year's Executive Forum, we've gathered an impressive lineup of speakers that we believe will add invaluable enrichment to our attendees' businesses."

General Session Topics and Speakers

  • ACA Requirements and Actionable Data -- John Barlament, Quarles & Brady, LLP
  • Will the Long-term Impact of ACA Expand or Shrink Self Funding? -- Tim Jost, Law Professor and Commentator
  • Applying Alternative Risk Strategies to Stop Loss Underwriting Solutions -- Gary Hudgins, Prodigy Health Insurance; Doug Thomas, Northwind; Barbara Tomlin, RGA Reinsurance; John Youngs, Prodigy Health Insurance
  • Medicare Reference Based Benefits Plans - "What a Difference a Year Makes, or Does it?" -- Jim Farley, J.P. Farley and Steve Rasnick, Self Insured Plans, LLC
  • Emerging Technology Implications for the Improvement of Population Health Outcomes -- Dr. Ashish Abraham, Altruista Health
  • How Strategic Planning Blends Passion, Achievement & Wealth -- Ernie Clevenger, CareHere, LLC
  • How to Boost Your Brand -- Russ Krueger, Ocozzio
  • Affordable Care Organizations and Third Party Administrators - Changing the Future Landscape of Healthcare -- Jack Hill, Accountable Care Solutions Group and Dan Holets, Consultant

All HCAA members, as well as non-member TPAs are invited to attend this conference. Registration and more information is now available on the HCAA website.

About HCAA

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


Symetra's Ratings Affirmed by Fitch

MyHealthGuide Source: Fitch via Business Wire, 12/12/2014, and Fitch

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 has been revised to Negative. A full list of rating actions follows at the end of this release.

Key Rating Drivers Includes Stop Loss

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 and the company's reliance on its niche group medical stop-loss business, which generates a significant but sometimes volatile source of earnings, and moderate profitability compared to similarly rated peers.

The Outlook is revised to Negative 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. 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. Given its liability mix, Symetra is more exposed to this risk than peers.

Symetra's risky asset ratio is in line with life industry levels, declining to 84% at Sept. 30, 2014 from 91% at year-end 2013. Symetra takes its equity exposure in the form of greater weighting of commons stocks and carries a lower exposure to private equity. 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 bond portfolio has avoided concentrations in troubled asset classes.

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 in good standing at Sept. 30, 2014.

About Fitch

Fitch Group is a global leader in financial information services with operations in more than 30 countries. Fitch Group is comprised of: Fitch Ratings, a global leader in credit ratings and research; Fitch Solutions, a leading provider of credit market data, analytical tools and risk services; Fitch Learning, a provider of learning and development solutions for the global financial services industry; and Business Monitor International, a provider of country risk and industry analysis specializing in emerging and frontier markets.  Visit


People News

Data Dimensions Welcomes  Mark Golino as New Chief Information Officer

MyHealthGuide Source: Data Dimensions, 12/12/2014,

JJANESVILLE, WI -- Data Dimensions is pleased to announce the addition of Mark Golino to its executive leadership team as Chief Information Officer, where he will direct all technology for the company.

Golino brings more than 25 years of data center management and senior-level technology experience with him to Data Dimensions. He has worked extensively in technology management and has designed, built and deployed high-capacity data centers, OCR solutions and natural language processing solutions. Golino has managed multiple teams of employees and several projects simultaneously, and he has extensive experience in application development, research and design.

"I'm very excited to welcome Mark to our executive leadership team," says Jon Boumstein, Data Dimensions President and CEO. "He brings a wealth of knowledge and experience to Data Dimensions, and he will help us reach new levels of growth and success in the coming years."

The addition in December of Mark Golino winds up a busy year for Data Dimensions. In November, HealthEdge completed its investment in Data Dimensions, enhancing growth opportunities for both companies. Earlier that month, Data Dimensions completed its acquisition of Olim Technologies Group, a long-valued partner. This summer, the company hired its 1000th employee and announced plans to open a new facility in Mt. Sterling, KY. And in August, Data Dimensions earned a spot for the second time on Inc. Magazine's exclusive Inc. 5000 list of the nation's fastest growing private companies.

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.  Call 800-782-2907 and visit

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


Magellan Health Appoints Dr. John Agwunobi to Board of Directors

MyHealthGuide Source: Magellan Health (NASDAQ: MGLN) via Business Wire, 12/11/2014,

SCOTTSDALE, AZ -- Magellan Health, Inc. announced that Dr. John O. Agwunobi has been appointed to the Magellan Health board of directors, for a term ending at the 2015 annual meeting of shareholders. In connection to the appointment of Agwunobi, the board increased its membership from nine to ten members.

"Dr. John Agwunobi's experience includes direct patient care, government service and advisory roles, as well as private sector health leadership and innovation," said Barry M. Smith, chairman and chief executive officer of Magellan Health. "As Magellan continues its work in population health management, his intimate understanding of state and federal health programs, coupled with his work bringing healthcare to consumers where they can most easily and efficiently access it, will be a valuable addition to our company's board. I look forward to working with him in this new capacity."

From September 2007 to April 2014, Agwunobi served as the senior vice president and president of health and wellness of Wal-Mart Stores, Inc., where he was responsible for all health related businesses for the company in the United States and Puerto Rico. He previously served as the assistant secretary for health in the U.S. Department of Health and Human Services from 2005 to 2007, where he was a principal advisor to the secretary on matters related to health and science. From 2001 to 2005, Agwunobi served as the secretary of health for the State of Florida, where he reported directly to the governor and was a member of the governor's cabinet. Agwunobi is a board certified pediatrician and holds both a Master of Public Health and a Master of Business Administration degree. He previously served as the chair of the U.S. African Development Foundation and as an interim executive board member of the World Health Organization.

About Magellan Health

Headquartered in Scottsdale, Ariz., Magellan Health, Inc. is a healthcare management company that focuses on fast-growing, complex and high-cost areas of healthcare, with an emphasis on special population management. Magellan delivers innovative solutions to improve quality outcomes and optimize the cost of care for those we serve. Magellan's customers include health plans, managed care organizations, insurance companies, employers, labor unions, various military and government agencies, third party administrators,  consultants and brokers. Visit


Market Trends, Studies, Books & Opinions

A New Type of ERISA-Based Hold-Up: The Rise of Out-of-Network Provider Suits Against Self-Funded Health Care Plans

MyHealthGuide Source: Michael T. Graham and Amy Gordonon, McDermott Will & Emery LLP, BNA Pension & Benefits Daily™, 10/27/2014, The Bureau of National Affairs, Inc. (800-372-1033),
Over the past decade, there has been a significant increase in the number of physicians who have dropped out of PPO and HMO networks and attempted to negotiate their own financial reimbursement with insurance companies and self-funded health care plans related to medical treatment provided to participants whose plan are governed by ERISA.

These moves have led to a corresponding increase in the number of health care benefit suits brought by out-of-network physicians and treatment centers seeking to gain through litigation that which they could not get through direct negotiations with insurers and plan administrators-- higher reimbursement amounts for health care treatment from ERISA-governed medical plans.

Many of these suits first centered on the transparency provided by insurance companies and ERISA plans in determining the UCR for which out-of-network physicians would be reimbursed.

The physicians argued that the insurance companies and plan administrators were hiding the true basis for how they would determine the objective reimbursement rates for the physician's out-of-network services, while the insurance companies and plans argued that the physicians unreasonably inflated their treatment fees in an effort to receive increased out-of-network reimbursement.

From these larger theoretical fights, individual physicians and treatment centers have entered the fray--with the individual physicians or groups looking to recover for allegedly undervalued UCR determinations on a participant-by-participant basis.

These relatively new out-of-network provider suits are now filling the federal district courts and ERISA plan administrative claim dockets with cookie-cutter lawsuits seeking to re-write the rules by which out-of-network treatment is reimbursed.

About the Authors

Michael T. Graham ( is a partner in the law firm of McDermott Will & Emery LLP and is based in the firm's Chicago office. His practice specializes in employee benefits litigation and controversy matters, advising plan administrators and fiduciaries on proper compliance with ERISA's claims and appeals procedures and litigating benefit matters in state and federal courts around the country.

Amy Gordon ( is a partner in the law firm of McDermott Will & Emery LLP and is based in the firm's Chicago office. Her practice focuses on welfare benefits compliance; specifically, she advises clients on issues related to the Health Insurance Portability and Accountability Act (HIPAA), the Public Health Service Act, the Affordable Care  Act (ACA), ERISA, and the Code.


Legal, Legislative & Regulatory News

Court Rejects Group's and Carrier's Cross-Motions for Summary Judgment on Eligibility Issue, Remands Case for Trial 

MyHealthGuide Source: Thomas A. Croft, Esq., 12/12/2014,

Case: Regional Care Services Corp., et al. v. Companion Life Insurance Company, No. 12-16538, United States Court of Appeals for the Ninth Circuit, December 2, 2014.  Court's Opinion.

Comment: The most salient aspect of this opinion is its application of discretionary decision-making provisions in the Plan in deciding whether the stop loss carrier owed the claim at issue. Even so, the Court of Appeals reversed a summary judgment that the trial court had granted in favor of the group, and sent the case back for a trial on the merits.

The Court's brief opinion, available here, is technically an "unpublished" opinion. See first asterisk at the beginning of the Court's Opinion, stating that that the decision "…is not precedent except as provided by 9th Cir. R. 36-3." The effect of this "unpublished" designation is presently unclear to this writer, as the cited rule states that unpublished opinions "are not precedent," but may be cited to courts within the circuit "in accordance with [Federal Rule of Appellate Procedure] 32.1." That Rule (applicable to all Courts of Appeal nationwide) expressly permits citation of unpublished opinions if issued after January 1, 2007. Whether the Federal Rule of Appellate Procedure affects the precedential value of the opinion--but only permits citation of it--is not readily apparent from a reading of the above-discussed rules.

In any event, the Court's analysis of the issues before it remains of interest, whether "precedential" in cases other than the one at hand or not.


At issue was the eligibility of an adopted dependent under the Regional Care Plan, and thus whether his claims were reimbursable under the stop loss carrier's contract with the group.

  • At the very outset, the Court of Appeals recognized that the substantive law of Arizona governed (presumably due to a choice of law provision in the stop loss contract), that the stop loss contract incorporated the Plan, and that Arizona law provided that insurance contracts are construed against the insurer if ambiguous.
  • Next, the Court noted that the Plan gave the Plan Administrator "maximum legal discretionary authority to interpret" the Plan and to decide eligibility questions. The Court further noted that the Plan declared that the decisions of the administrator would be "final and binding on all interested parties."

Based on these provisions, the Court of Appeals concluded that the carrier was bound by the Plan administrator's decision as to eligibility, "absent an abuse of discretion." In other words, the Court of Appeals applied an ERISA-type "abuse of discretion" deference to the Plan's decision-making. In doing so, the Court of Appeals principally relied on three Ninth Circuit cases (see footnote 6 of the opinion), all of which were ERISA cases involving claims for benefits by Plan beneficiaries, and none of which involved a stop loss contract. If there were any "anti-discretion" provisions in the stop loss contract at issue, the Court of Appeals did not refer to or discuss them.

Stop Loss Carrier Arguments

The carrier first argued that the Plan's requirement that natural children live with the employee applied to the adopted child involved. The Court of Appeals noted that there was no similar express requirement for adopted children, such that the language of the Plan was at least ambiguous on this point, and thus, under applicable Arizona law, should be construed against the stop loss carrier.

This would have been the end of matter, were it not for the Court of Appeals' observation that the Regional Care Plan also required that the Plan administrator carry out her duties "with care, skill, prudence and diligence."

The carrier argued that the administrator abused her discretion because the Plan required that the covered employee supply over one-half of the child's support, and that there was evidence, deemed by the Court of Appeals as "an unusual arrangement" whereby the child in question was placed with a guardian thousands of miles from the employee's household. The carrier argued that the Plan administrator had not conducted a reasonable investigation of the support issue before paying the claims at issue. The Court of Appeals agreed that issues of fact remained to be determined on this point, and remanded the case for further proceedings.

So, despite the extremely favorable "abuse of discretion" standard used by the Court of Appeals, the Plan administrator's decision was not blindly affirmed.

About the Author

Thomas A Croft is a magna cum laude graduate of Duke University (1976) and an honors graduate of Duke University School of Law (1979), where he earned membership in the Order of the Coif, reserved for graduates in the top 10% of their class. He returned to Duke Law in 1980 as Lecturer and Assistant Dean (1980-1982) and as Senior Lecturer and Associate Dean for Administration (1982-1984). He also taught at the University of Arkansas-Little Rock law school, where he was an Associate Professor of Law (1990-91), earning teacher of the year honors.

Until 2004, when he specialized in medical stop loss litigation and consulting, Tom practiced general commercial litigation. He was a partner in the litigation section of a major Houston firm in the late 1980s, and moved to the Atlanta area in 1991. He has been honored as a Georgia "Super-Lawyer" by Atlanta Magazine for the last eight years running, and holds an AV® Preeminent rating from Martindale-Hubble®.

Tom currently consults extensively on medical stop loss claims and related issues, as well as with respect to HMO Excess Reinsurance, Medical Excess of Loss Reinsurance, and Provider Excess Loss Insurance. He maintains an extensive website analyzing more than one hundred cases and containing more than fifty articles published in the Self-Insurer Magazine over many years. See He regularly represents and negotiates on behalf of stop loss carriers, MGUs, Brokers, TPAs, and Employer Groups informally, as well as in litigated and arbitrated proceedings, and has mediated as an advocate in many stop-loss related mediations. Tom can be reached at


TRIA Moves Closer to Renewal

MyHealthGuide Source: Willis Group Holdings plc, 12/9/2014,

Editor's Comment: The SIIA is a supporter of TRIA.

Reports from Washington, D.C. today indicate that Capitol Hill may be finally closing in on a potential compromise to renew the Terrorism Risk Insurance Program Reauthorization Act of 2007 or TRIPRA.

As we have previously reported, the US Senate on July 17th, in a vote of (93-4), passed a bill (S.2244) sponsored by Senator Charles Schumer (D-NY) to extend TRIPRA, with minor modifications. However, no similar legislative proposal was moved through the House due to firm opposition to the continuation of the program by key members of the House Financial Services Committee.

With Chairman Jeb Hensarling (R-Texas) stating as recently as this week that program extension would "violate House spending rules," a compromise seemed unlikely. He further went on to say that "if Senate Democrats continue to insist on their 'my way or the highway' approach … a long-term reauthorization may have to wait until the next Congress."

With Congress adjourning on the 11th of December, many have predicted a temporary, short-term extension which would achieve just that.

Now, initial reports of discussions held today between Chairman Hensarling, Senator Schumer, House Majority Leader Kevin McCarthy and other key members seem to indicate that a deal may be close to finalization, extending TRIPRA for six years, incrementally increasing the program threshold to $200 million (from the current $100 million) and the coinsurance percentage to 20% (currently 15%).

Many other provisions have yet to be negotiated, and it is not apparent how the dispute over the funding of the bill will be resolved. There may also be a bifurcation between program thresholds for nuclear, biological, chemical and radiological events and those deemed as "conventional terrorism."

While these encouraging signs signal movement away from the determined position of key House leadership, we caution that negotiations are still ongoing. While agreement on the key points may be imminent, there is still the possibility that the extension could not ultimately be finalized before the end of the current session.

About Willis

Willis Group Holdings plc is a leading global risk adviser, insurance and reinsurance broker. With roots dating to 1828, Willis operates today on every continent with more than 18,000 employees in over 400 offices. Willis offers its clients superior expertise, teamwork, innovation and market-leading products and professional services in risk management and transfer. Our experts rank among the world's leading authorities on analytics, modeling and mitigation strategies at the intersection of global commerce and extreme events. Visit


Medical News

Cholesterol Lowering Statin Does Not Reduce Bone Fractures

MyHealthGuide Source: Jessica M. Pena, M.D., M.P.H., Montefiore Medical Center and Albert Einstein College of Medicine, New York, 12/1/2014, JAMA Internal Medicine Abstract

Treatment with the anticholesterol medicine rosuvastatin (Crestor) did not reduce the risk of fracture among men and women according to a study published by JAMA Internal Medicine.

Fractures resulting from the bone-weakening disease osteoporosis are a burden facing an aging population. Cardiovascular disease (CVD) and osteoporosis may share common biological pathways with inflammation key to the development of atherosclerosis (hardening of the arteries) and possibly the development of osteoporosis. Several studies suggest statin users may have a reduced risk of fractures, while other studies find no association, according to the study background.

Researchers followed 17,802 patients enrolled in JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) trial. Participants had inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) levels of at least 2 mg/L. Participants were divided equally in two groups: one group received 20 mg daily of rosuvastatin while the other received placebo.

Study findings

  • There was no significance difference in the rate of fractures among the group of patients who took the statin and the group
  • There were 431 fractures reported during the study with 221 fractures among participants who took rosuvastatin compared with 210 fractures among individuals who received placebo, according to the study results.
  • The incidence of fracture in the rosuvastatin group was 1.20 per 100 person-years and in the placebo group 1.14 per 100 person-years.
  • Overall, higher baseline hs-CRP level was not associated with an increased risk of fracture.


Recurring Resources 

Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 11/1/2014)

Source: MyHealthGuide

Editor's Note: The following is a recurring article. This Newsletter is often asked by readers for a list of medical stop-loss providers and their respective premiums. Below the first of a recurring article that attempts to lists stop-loss providers and annual premiums. Sources includes press releases, AM Best reports, conference presentations and more.

Stop-loss Premium Ranking
Compiled by MyHealthGuide Newsletter

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

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
Capital /Equity
1. CIGNA     $1,907
  CIGNA 2013 10-K, page 46 2/27/2014
2. Sun Life Financial     $915.2
  Scott Beliveau, Sun Financial 4/28/2014
3. HCC Life Insurance Company >35 Years HCC Life
(A.M. Best Rated: A+)
Perico Life
(A.M. Best Rated: A+)
2014 10Q (2x $431 for 6 mons)
$3,900 HCC Insurance Holdings, Inc. Release,
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
Mike Sullivan, President & COO
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $475M
MRM - $255M)
Michael Fry, Executive Vice President, Symetra;
Mike McLean, Chairman Medical Risk Managers, Inc.
6. ING Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
Joe Keller, Lead Financial Analyst, ING Employee Benefits,
7. Companion Life > 20 Years   $440
  Philip Gardham, Vice President, Specialty Markets,
8. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
9. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
$200   Roy T.K. Thung, CEO, Letter to Stockholders
10. Zurich North America     $130   Tracey Brennan, Zurich North America.
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
  Victor Moran, Second Vice President, Actuarial Operations.  3/12/2014
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $$3,388
Mark Nichols, Managing Director.

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

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

Stop-loss Premium Volume is not the Whole Story

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

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

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


Upcoming Conferences

January 18-20, 2015
The 2015 Taft-Hartley Benefits Summit presented by Financial Research Associates, LLC.
Caesars Palace in Las Vegas. Contact Jennifer Clemence at  Information and registration: and visit

January 25-27, 2015
AAPAN 2015 Annual Forum presented by American Association of Payers Administration & Networks.  The theme for this year's forum is "Thinking Forward -- Rethink, Retool, Realign." This will be your opportunity to join industry leaders and an exciting lineup of speakers as we examine how best to position our businesses in this fundamentally changed healthcare environment. You will hear firsthand from experts and colleagues about challenges and opportunities at the state and federal level that are unique to TPAs, PPOs, and Workers' Comp professionals. Information: and (502) 403-1122.  Ritz-Carlton, Laguna Niguel in Dana Point, CA.

February 4-5, 2015
11th Annual Executive Forum on Rewarding Healthy Behaviors presented by World Congress.  Featured: Nicholas "Dr. Nick" Yphantides, MD, MPH; Chief Medical Officer, Health & Human Services Agency, San Diego County.  With National Health Care reform and the emerging priority of population health, employers have the opportunity to think outside the workplace box with regard to design and implementation of their health and wellness programs. Dr. Nick will highlight and illustrate the opportunities for employers to be proactive in partnering or at least aligning with regional population health innovations. As someone who has spent much of his professional career as a "board certified medical hypocrite," he brings a very personal and passionate perspective to the current strategic opportunities for employer based transformational interventions. Bellagio Las Vegas.  Information and registration: 781-939-2400 or 

February 9-11, 2015
2015 Executive Forum presented by Heath Care Administrators Association (HCAA).  Featuring:  A Physician-Senator's Look Into the Crystal Ball of Healthcare Reform (Senator Bill Frist, M.D.), Will the Long Term Impact of ACA Expand or Shrink Self Funding? (Tim Jost, Law Professor and Commentator) and other experts. Encore at Wynn Las Vegas. Las Vegas, NV.

March 4-6, 2015
Self-Insured Health Plan Executive Forum presented by Self-Insurance Institute of America.  J.W. Marriott Camelback, Scottsdale, AZ.

March 18-20, 2015
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA).

April 13-15, 2015
International Conference presented by Self-Insurance Institute of America. Latin America is a promising new frontier for self-insurance/captive insurance. Based on this perspective, SIIA is taking its International Conference to one of the leading economic hubs in Latin America to explore and discuss emerging self-insurance business opportunities in this important region of the world. Consistent with this outlook, the educational program will cover the following topics:

• Evolving regulatory environment for self-insured health plans in Latin America
• Captive insurance opportunities in Latin America
• Multi-national pooling for group benefits programs in Latin America
• Evolving roles for TPAs, brokers and carriers in Latin America
• Insurance carrier panel discussion
• The Panama Canal - a self-insurance case study
• Self-insurance opportunities in the Caribbean
• Medical travel in Latin America

Hilton Panama, Panama City, Panama.  Call 800/851-7789 and visit

April 29-30, 2015
Self-Insured Taft-Hartley Plan Executive Forum (NEW EVENT!) presented by Self-Insurance Institute of America. This one-day forum features a focused educational program designed to showcase self-insurance strategies and information that is sure help unions provide even more robust benefits while more effectively controlling costs. Register before February 27, 2015 and take advantage of discounted early bird fees. SIIA room block at the Marriott Metro Center will be released on April 7, 2015, so if you would like to stay at the host hotel, please register and make your room reservations at your earliest opportunity as we expect the hotel to be sold out. Marriott Metro Center, Washington, DC.  Information and registration: 

May 6-8, 2015
Northshore's 26th Annual Claims Conference.  Salem, Massachusetts. This is an invitation only event. If you are interested in attending or presenting at next year's conference, you may contact Steve Murphy at

May 12-14, 2015
Self-Insured Workers' Compensation Executive Forum presented by Self-Insurance Institute of America. Windsor Court Hotel, New Orleans, LA

July 21-23, 2015
MCIA Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA) at the Lodge at Whitefish Lake in Whitefish, MT.  Contact and visit

October 18-20, 2015
National Educational Conference & Expo presented by Self-Insurance Institute of America. Marriott Marquis, Washington, DC

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


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

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


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

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


Editorial Notes, Disclaimers & Disclosures

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