MyHealthGuide Newsletter
News for the Self-Funded Community
6/29/2009
Published weekly by MyHealthGuide, LLC (www.MyHealthGuide.com). This Newsletter is for personal, non-commercial use only. This weekly newsletter is FREE OF CHARGE to subscribers. Subscribe free. Send news, press releases and announcements to mailto:Info@MyHealthGuide.com.
TABLE OF CONTENTS
CBCA Administrators Partners with VIIAD Systems to Deliver Innovative Health Ticket Technology
HealthCare Insight® Launches StopHealthCareFraud.com To Aid Action Against Health Care Fraud
Sun Life Financial Provides Outplacement Resources Program for Group Benefits Customers
Indiana Health Centers Names Kari Niblack as Chief Human Resources Officer
Market Trends, Studies & Books
Legal, Legislative & Regulatory News
Health Plan Participant's Emotional Distress Charge Preempted by ERISA
Editorial Notes, Disclaimers & Disclosures
CBCA Administrators Partners with VIIAD Systems to Deliver Innovative Health Ticket Technology
MyHealthGuide Source: CBCA Administrators, Inc., 6/25/09, www.cbca.com and www.viiad.com
COLUMBUS, OH — CBCA Administrators, Inc. (CBCA) announced a strategic partnership with VIIAD Systems, LLC to deliver VIIAD’s
innovative Health Ticket technology to its book of business.
Understanding that ease of use is a key component in a member’s decision to
utilize their employer’s health plan, CBCA sought a technology that provides
accurate, simplified health plan information in an “easy access” format.
VIIAD’s Health Ticket provides the perfect combination of information and
simplification.
Customized Health Tickets are printed on demand by members or healthcare
providers prior to a physician visit or hospital admission. Listing
personalized information such as co-pay instructions, deductibles and more,
the Health Ticket clearly outlines a member’s financial responsibility.
Armed with this real-time knowledge, members make better healthcare
decisions.
“Programs like VIIAD’s Health Ticket are changing the way members utilize
their health plans for the better,” states Ken Di Bella, President and CEO,
CBCA Administrators, Inc. “Empowering members to make responsible choices is
the first step to lowering healthcare costs.”
“As a result of the Health Ticket, CBCA’s client base is reducing
out-of-network claims, increasing members’ knowledge of their health plan,
and improving overall member and provider communications,” said April
Stiles, COO of VIIAD Systems. “We are excited that the Health Ticket is an
integral component of CBCA’s forward thinking product strategy.”
About CBCA Administrators, Inc.
CBCA Administrators, Inc. (CBCA) is a full-service benefits management company with offices across the nation. CBCA combines proven strategies, integrated service applications, and innovative products to create a single source for effective health plan management. CBCA partners with employers to identify, implement, and integrate solutions to solve the issues that are most important to our clients. Our expertise and flexibility allow us to bring the best solution to any benefit program. Headquartered in Columbus, Ohio, CBCA also has offices in Ft. Worth, Texas, Minneapolis, Minnesota and Savannah, Georgia. Contact Rodney Napier, Chief Marketing Officer at (614) 635-8656 and visit www.cbca.com.
About VIIAD Systems, LLC
Founded in 2006, VIIAD’s objective is to advance our clients competitive position by providing innovative solutions that reduce costs, maintain compliance and improve the health care experience. VIIAD’s patent pending Health Ticket is a simple, elegant technology solution that was awarded “2008 Risk Innovator of the Year” by Risk and Insurance Magazine. Contact Wayne Cluff at (866) 498-4423 and visit www.viiad.com.
MyHealthGuide Source: HealthEdge, 6/23/09, www.healthedge.com and www.buildersbenefits.com
Burlington, MA — HealthEdge, provider of the only modern,
enterprise-class software platform for healthcare payors, announced
that Pennsylvania-based Builders Benefits has completed their implementation
of the HealthRules product suite. The advanced technology of HealthRules
will now be used to power the next phase of growth and efficiencies for
Builders Benefits.
The patented, one-of-a-kind HealthRules software suite allows healthcare
payors to rapidly respond to new business opportunities and market
changes—in hours, not weeks or months—while reducing costs and increasing
operational efficiencies. Organizations using the HealthRules platform gain
the ability to compete more effectively in the emerging consumer-centric
healthcare marketplace, as they are now able to quickly offer the kinds of
innovative products that the market demands.
"We believe that the advanced capabilities offered by the HealthRules
product suite are truly revolutionary," said Steve Rock, CEO of Builders
Benefits and former CEO of Amisys and Synertech. "We are excited to have
chosen HealthEdge to provide the next-generation technology foundation for
our business. With HealthRules now in place, I am confident that we will be
able to quickly adapt to the changing needs of our customers and continue to
improve efficiencies and reduce administrative costs."
"More and more payor organizations are turning to the patented,
one-of-a-kind HealthRules product suite to efficiently address the evolving
business imperatives of today's healthcare marketplace," said Rob Gillette,
CEO of HealthEdge. "We are excited to add Builders Benefits to our growing
list of live customers, and we look forward to continuing to work closely
with them on their upcoming business initiatives."
About HealthEdge
HealthEdge provides the only modern, enterprise-class software platform for
healthcare payors. Using the patented HealthRules® software suite, health
plans, health insurance companies and other payors can finally respond to
new business opportunities and market changes in hours, not months or years,
while drastically reducing both IT and operational costs. Leveraging an
investment of over $125 million in information technology, HealthRules is
the most modern, scalable and cost-effective technology in the industry.
HealthEdge is the only choice for payors to survive and thrive in the
emerging healthcare economy. Visit
www.healthedge.com.
About Builders Benefits
Builders Benefits focuses on providing top quality health insurance options
for companies working in Pennsylvania’s building industry. Established in
December 2006, Builders Benefits provides coverage to over 20,000 members. A
choice of Preferred Provider Organization (PPO) plans with varying
deductible levels is offered to help business owners choose the coverage
they need at an affordable cost.
Headquartered in Harrisburg, Pennsylvania, Builders Benefits is a
wholly-owned subsidiary of the Pennsylvania Builders Association Benefits
Trust offering to members of the building industry who join the Trust a
self-insured health plan. Visit www.buildersbenefits.com.
MyHealthGuide Source: HealthCare Insight® (HCI), 6/22/09, www.hcinsight.com and www.StopHealthCareFraud.com
SALT LAKE CITY, UT – HealthCare Insight® (HCI), a Verisk Health company and a provider of clinically validated fraud, abuse, and overpayment prevention solutions for private and public-sector payors, announced today that the company launched StopHealthCareFraud.com to help consumers identify and report health care fraud.
According to the National Health Care Anti-Fraud Association (NHCAA), health care fraud accounts for 3 to 10% of total annual U.S. health care costs. At almost $250 billion in 2009, the money lost to fraud could potentially insure up to 30 million more Americans, approximately 60% of our country’s uninsured population. In 2009, health care fraud will cost Americans with health care coverage an average of $200 to $800 per person.
The impact of fraud also manifests itself in the form of higher premiums, lost health benefits, inaccurate medical records, and increased out-of-pocket health spending. StopHealthCareFraud.com is dedicated to helping consumers understand, identify, and take action against health care fraud to combat fraudulent provider activity and save consumers and payors billions of dollars annually. The site is loaded with tips, statistics, and other resources to help consumers become aware and stay informed of emerging trends and fraud schemes.
“We are very excited to launch StopHealthCareFraud.com. Unfortunately, most Americans don’t realize the scale, cost, and overall impact of the fraud problem, which underscores the need for a resource like this. Health care fraud is a serious crime that affects every participant in the health care system, including providers, insurers, government programs, and consumers This site is an essential tool to promote awareness and get consumers to take action and join the fight against fraud.” said Darin Johnson, vice president of marketing for HealthCare Insight.
Features of the site include:
About HealthCare Insight® (HCI)
HCI, a Verisk Health company, provides private and public sector health care claims payors (including health plans, managed care organizations, insurance carriers, third-party administrators, Medicaid, and Medicare) with a comprehensive suite of clinically validated fraud and abuse surveillance services designed to maximize claims administration accuracy and minimize payment waste. Each of HCI’s customizable software-as-a-service (SaaS) solutions relies on a unique prepayment process that combines proprietary software systems with detailed review by experienced clinicians (doctors, nurses, and dentists) and investigators on all suspect claims and billing patterns. HCI’s differentiated process enables payors to target fraud with greater efficiency by significantly increasing the quality of results returned. Call 877-619-5557 and visit www.hcinsight.com.
Sun Life Financial Provides Outplacement Resources Program for
Group Benefits Customers
MyHealthGuide Source: Sun Life Financial (NYSE: SLF, TSX: SLF), 6/22/09,
www.sunlife-usa.com and
www.compsych.com
Wellesley, MA – The Employee Benefits Group division of Sun Life Financial
Inc. is now offering a new,
comprehensive outplacement resources program to its self-funded customers enrolled in
the ComPsych employee assistance program (EAP). The OutplacementResourcesSM
program, available through ComPsych® Corporation, is a cost-effective
benefit that includes information, tools and resources to help former
employees in transition as well as human resources managers.
“We know that employers are looking for innovative ways to support employees
in today’s economic climate,” said Scott Beliveau, VP, Multi-Line Product
Center. “By working with ComPsych, we are able to extend additional,
cost-effective benefits to employers that are vital to maintaining morale,
as well as providing employees with valuable tools for their transition.”
OutplacementResources is designed for organizations of all sizes that wish
to support former employees of all levels and provide them with practical,
effective job-hunting skills.
The program includes three components:
This outplacement services program is now available to Sun Life’s customers
who are enrolled in the EAP program offered through ComPsych. Based on the
partnership, this service will provide an exclusive discount for Sun Life
customers. Comprehensive EAP programs – including a wide range of work-life
services – are offered to all of Sun Life’s group life, long-term disability
(LTD), short-term disability (STD) and self-insured customers.
About Sun Life Financial
Sun Life Financial is a leading international financial services organization providing a diverse range of protection and wealth accumulation products and services to individuals and corporate customers including medical stop loss for self-funded employers. Chartered in 1865, Sun Life Financial and its partners today have operations in key markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China and Bermuda. As of March 31, 2009, the Sun Life Financial group of companies had total assets under management of US $297.5 billion. Visit www.sunlife-usa.com.
About ComPsych
Founded in 1984, ComPsych is the world’s largest provider of global employee
assistance programs (EAPs) and is the pioneer and leading provider of fully
integrated EAP, behavioral health, wellness, work-life, crisis intervention
services and outsourced HR solutions under the GuidanceResources brand.
ComPsych provides services to more than 29 million individuals and 11,000
organizations throughout the U.S. and 97 countries. Clients range from the
Fortune 500 to smaller public and private concerns as well as government
entities and Taft-Hartley groups. ComPsych creates “Build-to-Suit” programs
which help employers attract and retain employees as well as improve
employee productivity and performance. Visit
www.compsych.com.
Indiana Health Centers Names Kari Niblack as Chief Human Resources Officer
MyHealthGuide Source: Indiana Health Centers, Inc., 6/22/09, www.ihcinc.org
INDIANAPOLIS, IN – Kari L. Niblack, JD, SPHR, has been appointed Chief Human Resources Officer for Indiana Health Centers, Inc., a self-funded Indianapolis-based network of federally qualified community health centers across Indiana that provides medical and dental care to 65,000 clients statewide. Most patients have no health insurance, are underinsured, or unemployed.
Niblack was Vice President and division leader of the two largest and
leading TPAs Indiana. She was a vice-president with SIHO Insurance
Services, Inc., from 2006 to 2008 and vice-president of client
relations at Key Benefit Administrators (2004-2006). Prior work experience
includes serving as director of alumni programs at Indiana University Kelley
school of Business (2002-2004), and as legal counsel in the retirement
services division for American United Life Insurance (2001-2002).
.
She is a licensed attorney in both Indiana and Florida and a licensed
producer in Indiana in life, health, property and casualty insurance.
Niblack serves as an adjunct professor at Indiana University’s Kelley School
of Business, teaching law, ethics, and human resources management courses,
and was awarded a 2008 Faculty Teaching Award.
.
Niblack holds a bachelor’s degree in criminal justice from Indiana
University and earned her JD degree from Nova Southeastern University Law
School in Fort Lauderdale, Florida.
About Indiana Health Centers
Indiana Health Centers provides comprehensive health services at eight locations statewide to more than 65,000 patients who are unemployed, underemployed or uninsured. Among other benefits, the service saves self-funded employers and other payers from absorbing the costs from unnecessary emergency room and other utilized hospital resources. Contact Kari Niblack at (317) 576-1335, kniblack@ihcinc.org and visit www.ihcinc.org.
The Leapfrog Group Elects David Knowlton Board Chair
MyHealthGuide Source: The Leapfrog Group, 6/25/09, www.leapfroggroup.org
WASHINGTON, DC – David Knowlton has been elected Chair of The Leapfrog Group Board of Directors, effective June 17, 2009.
Knowlton is President and CEO of the New Jersey Quality Institute, an influential advocacy organization that works with that state’s most influential employers to drive health care improvement. Knowlton is also active on the national level representing private sector purchasers of health care in numerous forums, boards, and organizations.
Formerly Deputy Commissioner of Health for the State of New Jersey during the administration of Governor Tom Kean, he has been published numerous times on issues dealing with health care quality and management. He frequently speaks to national organizations and testifies on purchaser perspectives on health care reform. Knowlton was one of Leapfrog’s pioneers and has served on the board for the past seven years.
“Dave’s record of accomplishment in health care quality, advocacy, and policy will be critical to Leapfrog as we continue to assert purchasers’ agenda for major improvement in quality and efficiency of hospital care,” said Leapfrog CEO Leah Binder. “Dave brings a vision for change coupled with pragmatic understanding of what it will take to accomplish our goals. Dave has been involved with Leapfrog almost since its inception nine years ago and his leadership has helped make Leapfrog a critical force in health care nationally and at the regional level—and we need his guidance now more than ever as health care reform takes center stage in Washington.”
Leapfrog is the consensus public reporting initiative of private sector purchasers of health care and a leading advocate of 100% transparency of health information.
“I am excited to take on this role at this historic time,” said Knowlton. “The information on quality, safety, and efficiency available publicly only from Leapfrog’s Hospital Survey, coupled with Leapfrog’s longstanding leadership in changing the way purchasers do business with hospitals, is literally indispensible to successful health care reform.”
About The Leapfrog Group
On behalf of the millions of Americans for whom many of the nation’s largest corporations and public agencies buy health benefits, The Leapfrog Group aims to use its members’ collective leverage to initiate breakthrough improvements in the safety, quality, and affordability of health care for Americans. The Leapfrog Group was founded in November 2000 by the Business Roundtable and is supported by its members, the Robert Wood Johnson Foundation, The Commonwealth Fund, the Agency for Healthcare Research and Quality and other sources. Visit www.leapfroggroup.org.
Market Trends, Studies & Books
Emerging Data on Consumer-Driven Health Plans Shows Savings
MyHealthGuide Source: American Academy of Actuaries (AAA), 5/2009, AAA CDHP Monograph
This study recommended by Roy Ramthun, "Mr. HSA", HSA Consulting Services, LLC, 202-747-4467, 6/15/09, www.hsaconsultingservices.com.
Consumer-driven health (CDH) products have been marketed in various forms since the early 2000s. While emerging data is not entirely conclusive, general directional conclusions can be drawn from the studies published to date. The AAA monograph summarizes the results of some of those studies, focusing on the ones that are based on historical claims data, that use credible methodologies, and that provide reasonably detailed and relevant results.
The observations of this monograph are organized around four main questions that are frequently raised regarding CDH plans:
Study Findings
Generally, all of the studies indicated that cost savings did not result
from avoidance of inappropriate care and that necessary care was received in
equal or greater degrees relative to traditional plans. All of the studies
reviewed reported a significant increase in preventive services for CDH
participants. Three of the studies found that CDH plan participants received
recommended care for chronic conditions at the same or higher level than
traditional (non-CDH) plan participants. Two studies reported a higher
incidence of physicians following evidence-based care protocols.
Finally, the studies indicated that while the possibility for employer
cost-shifting exists with CDH plans, (as it does with traditional plans)
most employers are not doing so, and might even be reducing employee
cost-sharing under certain circumstances.
About American Academy of Actuaries
The
American Academy of Actuaries serves the public on behalf of the U.S.
actuarial profession. Uniting actuaries from all practice areas, the Academy
is the voice of the profession on public policy and professionalism issues.
The purposes of the Academy's work are described in the mission, which was
updated in 2007. The Academy was created in 1965 and is headquartered in
Washington, DC. Visit www.actuary.org.
Legal, Legislative & Regulatory News
MyHealthGuide Source: Roy F. Harmon III, Esq., Health Plan Law, 6/23/09, www.healthplanlaw.com
Case: Anderson v. Dergance, 2009 U.S. Dist. LEXIS 51593 (N.D. Ill. 6/18/09)
This ERISA plan reimbursement case applies the Sereboff holding to find in favor of an ERISA plan’s claims to specifically identifiable funds held in an attorney’s trust account following a personal injury settlement.
...the claim for reimbursement is properly brought as a claim for equitable relief in accordance with both ERISA and the terms of the Plan. See Sereboff v. Mid Atl. Med. Servs, Inc., 547 U.S. 356, 126 S. Ct. 1869, 164 L. Ed. 2d 612 (2006) (providing that an ERISA fund was entitled to recover on an equitable relief claim because it sought to recover specifically identifiable funds under ERISA §502 (a)(3)); Admin. Comm. of the Wal-Mart Stores, Inc. Assocs. Health & Welfare Plan v. Varco, 338 F.3d 680, 688 (7th Cir. 2003).
Case Background
Cory Dergance was injured at a Dollar General store and subsequently settled
a personal injury claim for $30,000. Medical bills for the personal injury
had been paid by the Painters’ District Council No. 30 Health and Welfare
Plan (the “Plan”), administered by Plaintiff Painters’ District Council No.
30 Health and Welfare Fund (the “Fund”), an ERISA multiemployer.
Dergance’s attorney in the personal injury case,
Peter Ferracuti, held $14,365.13 in benefits paid to Dergance.
The Reimbursement Claim
A dispute over reimbursement led to litigation in which the plan asserted a
claim for equitable relief. The issue came before the court in the posture
of a summary judgment motion.
As is frequently the case, the plan’s procedures regarding acknowledgment of
a repayment obligation created some room for argument over the plan’s
rights. Dergance had never signed the “subrogation agreement” document as he
was required to do under the plan terms for benefits to be paid.
Thus, the argument:
Citing to Plan section 2.17(b)(5), [plaintiff's attorney,] Ferracuti argues that a subrogation/agreement to repay document had to have been executed in order for the Fund to seek reimbursement. Ferracuti says that no such document was ever created or signed by Dergance.
The court appears to have applied something like an estoppel analysis without specifically describing the basis for its rationale as such. But the notion that the participant could accept benefits under the plan terms and then object to the plan repayment provisions seemed to have provoked the Court.
Dergance received his benefits under the Plan. Neither he nor Ferracuti may now use Plan provisions that are intended to ensure that Eligible Individuals receive their benefits in order to preclude the Fund from recovering the reimbursement to which it is entitled. This is not the type of protection envisioned by the Plan’s clear language.
The Court awarded summary judgment against Dergance and Ferracuti, jointly and severally, in the amount of $14,365.13.
“Clear Language” Cited by the Court
Note: The “clear language” cited by the Court was described as follows:
... section 2.17(b)(5) of the Plan states that “the Eligible Individual’s entitlement to benefits from the Plan shall be further conditioned upon the execution” of a subrogation/agreement to repay.
The clear language indicates that the execution of the agreement enables an Eligible Individual to seek the benefits to which he is entitled, i.e., the benefits are conditioned upon the execution of the agreement. The section does not indicate that reimbursement is conditioned upon the execution of the agreement. In addition, section 2.17(b)(6) provides that “[n]o benefits shall be payable by the Fund if an Eligible Individual . . . fails to execute a subrogation/agreement to repay.” These sections, including the need for a signature, are explicitly in addition to the Plan provision upon which the Fund relies. According to section 2.17(b)(4), “[n]otwithstanding any other provisions of this Plan, and in addition to such rights of recovery [*9] or offset, the Plan shall have a lien, enforceable as a provision of this plan . . . for the full amount due to the Plan.”
Separation Of Charges
The defendants presented a factual issue on the relatedness of medical payments to the accident. There was a proof problem here, however, as the court observed that:
With regard to the accuracy of the reimbursement amount for medical benefits and disability benefits, Ferracuti relies on a letter from Dergance’s doctor that separates charges related to Dergance’s injury at Dollar General from those related to a separate condition that was treated at the same time (a carpal tunnel release). Ferracuti cannot rely on the letter, as it is not only unsupported by affidavit, but also its contents were not presented in a L.R. 56.1 statement of facts. Even if I were to rely on the letter as evidence, by the doctor’s own admission, “it is difficult to separate the charges attributable to the carpal tunnel release from those that were incurred as a direct result of the laceration.” I have deemed the Funds’ stated reimbursement amounts as accurate.
Joint And Several Liability
The Court held that the lawyer was jointly and severally liable “because it is in possession of at least $14,365.13 of Dergance’s recovery.” Thus:
Ferracuti is not merely a nominal defendant, but rather a necessary party, who will be “affected by the judgment [of the court] and against [whom] it will in fact operate.” West Coast Exploration Co. v. McKay, 213 F.2d 582, 592, 93 U.S. App. D.C. 307 (C.A.D.C., 1954). The law firm is subject to suit because it hold funds which are subject to the Fund’s equitable lien.
The caption of the case reveals the attorney’s professional corporation was the defendant, not the attorney personally. This was proper because the corporation held the funds. Since Dervance held no funds, was there really jurisdiction over him for a joint and several judgment?
About Roy F. Harmon
Roy F. Harmon III, is a principal in Harmon & Major, P.A., a law firm located in Greenville, South Carolina, and has over twenty years experience in ERISA matters, from plan design and drafting to case controversies and litigation. He also serves as Vice President and General Counsel of Cost Recovery Systems, Inc., Greenville, South Carolina. He is a consultant, speaker and author on subjects involving ERISA group health plan administration. Visit www.HealthPlanLaw.com.
MyHealthGuide Source: Rebecca Moore, PLANSPONSOR.com, 6/17/09, PLANSPONSOR.com Article (requires free registration)
Case: Polley v. Harvard Pilgrim Health Care, D.N.H.,
No. 08-cv-392-SM
The U.S. District Court for the District
of New Hampshire has dismissed an employee's charge that her employer
negligently inflicted emotional distress on her by long delays and not
responding to her inquiries when processing her medical claims.
The court pointed out that both parties agreed that Louise Polley's Harvard
Pilgrim Health Care Inc. medical benefits were provided under an ERISA plan. "ERISA preempts all state laws
that ‘relate to’ employee welfare benefit plans," Chief Judge Steven J.
McAuliffe wrote in the court opinion. He rejected Polley's argument that she
was not claiming a loss of benefits, but was asserting that Harvard Pilgrim
knew or should have known she was emotionally vulnerable and its handling of
her claims would make her condition worse.
Case Background
Polley worked for Harvard Pilgrim until July of 2005, when she suffered a
nervous breakdown due to work-related stress and took a medical leave of
absence. During her leave of absence, which ended with her discharge in
December of 2005, Polley applied for short-term disability benefits through
Harvard Pilgrim’s employee-benefit program. The program administrator told
her to apply for workers’ compensation benefits, but her claim was denied.
After the Workers’ Compensation Division of the New Hampshire Department of
Labor also denied her claim, Polley filed an appeal. Harvard Pilgrim and its
workers’ compensation insurer agreed to pay her $52,000 to settle her claim.
Polley claimed that the three-month delay in receiving her settlement as
well as delays in her attempts to access medical and prescription benefits
provided by Harvard Pilgrim “caused her financial worry, further shame,
distrust, a worsening of her medical condition, and other damages.”
Emotional Distress Complaint Filed
According to the opinion, Polley sued Harvard Pilgrim in state court for
negligent infliction of emotional distress. After Harvard Pilgrim removed
the case to the federal court and moved for judgment on the pleadings,
Polley filed an amended complaint in which she re-asserted her claim for
negligent infliction of emotional distress and made a second claim,
asserting an ERISA violation. However, McAuliffe noted that because Harvard
Pilgrim’s motion for judgment on the pleadings was filed before Polley’s
amended complaint, it addresses only the emotional distress claim.
Court Dismisses Claim
The district court also dismissed Polley's claims that Harvard Pilgrim negligently inflicted emotional distress by committing a “series of egregious acts” in its handling of the circumstances surrounding her separation from employment, and the payment she was due under the settlement of her workers’ compensation claim, saying they are barred by the exclusive-remedy provision of the Workers’ Compensation Law. "Because Polley’s workers’ compensation claim, as characterized in the settlement agreement, sought recovery for injuries resulting from her discharge, she is barred from seeking such damages in this action," McAuliffe wrote.
About PLANSPONSOR.com
PLANSPONSOR.com is the nation's leading online resource for pension and retirement issues. PLANSPONSOR, via its publishing, online, email newsletter and education assets, provides comprehensive news, content, research, training and e-commerce solutions to benefits and retirement decision-makers nationwide. PLANSPONSOR's mission is to help these decision-makers, who oversee the welfare of millions of employees with trillions in retirement assets, navigate the complex world of retirement and provide the right solutions to their various constituencies. Visit www.plansponsor.com.
MyHealthGuide Source: Self-Insurance Institute of America (SIIA), 6/25/09, www.SIIA.org
As part of the association’s ongoing campaign, SIIA publicize how group self-insured (SIG) workers’ compensation funds are successfully serving the risk management needs of employers throughout the country.
The Missouri Merchants and Manufacturers Association (MMMA) Self-Insured
Workers’ Compensation Fund stands as a model of the self-insured group (SIG)
workers’ compensation insurance concept. The fact that its leaders worked
through the political system to change their state workers’ compensation
landscape in favor of all employers just makes it that much more
interesting.
At a glance, the MMMA Fund is a great success. Founded in 1992, it has more
than 100 members employing 11,000 with $300M in payroll. Total WC premium is
$6M. And through careful management and a rigorous loss prevention program,
the Fund has distributed $8M in surplus to its members.
MMMA Led Passage of WC Law
In 2005 MMMA led the passage of the most comprehensive
Missouri workers’ compensation reform bill! The definition of an on-the-job
injury was tightened, saving Missouri businesses millions in the last four
years.
But denying claims is not MMMA’s goal: “We firmly believe that legitimate
claims should be paid immediately,” says founding director Sheelah Yawitz
who is something of a legendary figure in Missouri business and politics.
“We select doctors we would use for our own families. We get the best
medical results and put people back to work as soon as possible,” she adds.
Ms. Yawitz saw inequities in the prior workers’ compensation system that she
accepted as a challenge to correct on behalf of MMMA members. When MMMA won
its campaign, State Senator John Loudon was quoted: “Sheelah Yawitz, on
behalf of MMMA, was pivotal in crafting the 2005 workers’ compensation bill,
bringing all parties together and passing a historic reform package to help
Missouri employers.”
Ms. Yawitz didn’t keep track of how many tires she used up commuting from
her headquarters in St. Louis to personally lead the MMMA lobbying effort in
the state capital. She credits her success on behalf of MMMA members to
three elements: “Persistence, knowledge and taking our message to a
business-supportive state administration and legislature,” she says.
“I can’t see that law passing any other way,” says Duke Niedringhaus, Vice
President of JW Terrill Inc., which provides excess workers’ compensation
brokerage services to MMMA. “No Sheelah, no success,” he emphasizes. “She
pulled together the attorneys and lobbyists involved and carried this
campaign through the legislative process. I use the ’05 Missouri law as the
benchmark of how workers’ compensation reform should be executed in other
states. What more would employers want from their work comp provider?” Mr.
Niedringhaus added.
Examples of the historic work comp reform law of 2005 include:
Law Results In Savings
Since passage of the workers’ compensation reform law,
MMMA’s quarterly review of all open claims and their knowledge of the law
have resulted in more accurate claim reserving. NCCI loss development for
Missouri is a 1.31 loss development factor at 15 months. For MMMA, there is
virtually no added loss development after its 15-month valuation.
MMMA members receive 2-4 on-site loss prevention visits annually at each
location. This is a true proactive partnership for MMMA members.
Missouri has long been known as the “show-me” state. Sheelah Yawitz and MMMA
have conclusively shown Missourians and those elsewhere that a self-insured
group workers’ compensation program can be a powerful tool for its members
and the state’s business community.
About Self-Insurance Institute of America
The Self-Insurance Institute of America, Inc. (SIIA) is a dynamic, member-based association dedicated to protecting and promoting the business interests of companies involved in the self-insurance/alternative risk transfer (ART) industry, both domestically and internationally. Visit www.SIIA.org.
New Patient Assay Helps Optimize Breast Cancer Chemotherapy
MyHealthGuide Source: DiaTech Oncology, 6/25/09, www.diatech-oncology.com
Nashville, TN – DiaTech Oncology announced results of a study with
breast cancer patients indicating that the Microculture Kinetic “MiCK” assay
may be used in the laboratory to directly measure apoptosis (cell death) of breast cancer
cells from individual patients when those cells are exposed to anticancer
drugs. By knowing which drugs can kill an individual patient’s cancer cells
in the test tube, a treating oncologist can have a guide to which drugs
might work most effectively in the patient.
The MiCK assay, invented at Vanderbilt University School of Medicine, is a
proprietary laboratory test to help physicians determine specific
chemotherapy needs for patients by measuring the response of the patient’s
own cancer cells to an array of different chemotherapeutic drugs. Although
it had been tested and validated previously in myelocytic leukemia patients,
this was the first study of this assay in breast cancer.
It has long been known that chemotherapy drugs used to treat cancer will
cause cancer cells that are sensitive to those drugs to undergo a process of
self-destruction called apoptosis. Measuring the amount of drug-induced
apoptosis in a patient's tumor cells in the lab prior to the drug treatment
in the patient will help doctors to select drugs to which tumor cells of the
patient are sensitive and thus, to increase the success rate of the
patient’s cancer chemotherapy.
Study Design
This study reported at ASCO 2009 was lead by Principal Investigator Pat
Whitworth M.D. of Nashville, Tenn. The trial investigated the MiCK assay as
a predictive breast cancer chemosensitivity test that will facilitate
individualized treatment. Unlike older assays, the MiCK assay measures
active apoptosis of malignant cells from an individual patient’s tumor
biopsy. 57 patients were evaluable for MiCK results.
Tumor excisions or biopsies from patients were sent to a central laboratory,
prepared using a previously described MiCK technology (Lab Invest 74: 557,
1996). Next, the tumor cells of the individual patient were exposed to
multiple therapeutic doses of several chemotherapeutic drugs or combinations
of drugs. Apoptosis was measured over 48 hours every 5 minutes. A
sophisticated lab analysis of the cancer cells was used to monitor and
compute the amounts of apoptosis caused by each of the drugs to establish a
drug sensitivity profile of the patient's tumor cells.
Knowing Patient's Sensitivity Improves Outcomes
Knowledge of a patient's drug sensitivity profile may allow the treating
Oncologists to prescribe chemotherapy that is effective against the tumor
cells of that patient. This may help the patient to receive the drugs likely
to produce a remission, enhancing the likelihood of a cure, and may avoid
unnecessary toxicity or side effects.
The MiCK assay may also reduce the cost of patients’ treatments by avoiding drugs that are unlikely to work or by indicating when generic drugs are as likely to work as more expensive alternatives.
Identifying a Single Cancer Drug That is More
Effective than Drug Combination
In the reported study, Dr. Whitworth and his co-investigators reported the
ability of a number of drugs to produce apoptosis in patient’s cancer cells.
Although in most cases the combinations of treatments worked better than
individual drugs, the test was able to identify individual patients in whom
just a single drug was as effective as or more effective than the
combination. Importantly, after prior chemotherapy, breast cancer cells show
altered chemosensitivity profiles, with persistent chemosensitivity to
doxorubicin or epirubicin, but reduced sensitivity to cyclophosphamide. This
indicates that patients would best have this test just prior to initiating a
new treatment.
“DiaTech is the only laboratory offering automated kinetic measuring of
apoptosis for clinical testing and direct determination of a patient’s
actual sensitivity to a chemotherapeutic agent,” said R. Garry Latimer, CEO
of DiaTech Oncology. “The MiCK assay is an important new tool for the
practice of personalized medicine.”
When a cancer patient's specimen is submitted for the MiCK drug sensitivity
study, the referring Oncologist receives a clinically important drug
sensitivity profile for the tumor cells of the individual cancer patient
from the DiaTech Oncology laboratory within 48 to 72 hours. Even in those
patients who have advanced cancers that have become resistant due to
multiple prior treatments, the MiCK assay may help doctors choose a drug
treatment that is still able to treat a patient’s tumor.
The MiCK assay may also be useful in speeding up the development of new
anticancer drugs and new drug-combination therapies.
About DiaTech Oncology
DiaTech Oncology is a clinical pathology laboratory whose knowledgeable physicians, technical staff and experienced management team are working to help oncologists and their patients deal with the devastating effects of cancer. We offer two major types of clinical services to our clients: patient specific anticancer drug sensitivity testing and diagnostic hematopathology. We work to accurately diagnose the disease and to arm the physicians with effective tools capable of eliminating a patient’s cancer cells or keeping tumor cells under effective control. Contact Garry Latimer or Cary Presant, MD, at 615-377-9668 and visit www.diatech-oncology.com.
Doctors Often Fail to Report Abnormal Test Results
MyHealthGuide Source: Archives of Internal Medicine, Vol. 169 No. 12, June 22, 2009, Abstract
Failures to inform patients of abnormal outpatient test results are far too common according to a study published in the Archives of Internal Medicine.
The study followed records of 5,434 randomly selected individuals aged 50 to 69 years in 19 community-based and 4 academic medical center primary care practices. Primary care practice physicians were surveyed about their processes for managing test results, and individual physicians were notified of apparent failures to inform and asked whether they had informed the patient. Blinded reviewers calculated a "process score" ranging from 0 to 5 for each practice using survey responses.
Study findings
Standard Stop-Loss Employer Disclosure Form Endorsed
MyHealthGuide Source: Self-Insurance Institute of America (SIIA, www.SIIA.org), Society of Professional Benefit Administrators (SPBA, www.SPBATPA.org), Recurring article
Self-Insurance Institute of America ( www.SIIA.org ) and Society of Professional Benefit Administrators (www.SPBATPA.org) have endorsed a standardized stop-loss disclosure form, which also includes ICD-9 codes. The documents are intended to help facilitate the sharing of health data information between self-insured entities/TPAs and stop-loss insurers/MGUs for the purpose of medical stop-loss underwriting.
Stop-Loss Carriers and MGUs Adopt the Standardized Form
The list below represents an estimated $3.3 Billion in Stop-Loss premium. Assuming a medical self-funded community Stop-Loss market of $4 Billion, then over 80% of the market has adopted the form.
If you are a Stop-Loss carrier or MGU that has adopted the standard disclosure form, please let us know at Info@MyHealthGuide.com.
Azeros Healthcare, MGU on behalf of London Life Reinsurance Company
BEST Re on behalf of US FIRE & BEST LIFE
HMA MGU, LLC, MGU
Independence Holding Company (Standard Security Life Insurance Company of New York, Madison National Life and Independence American Insurance Company)
Intermediary Insurance Services, Inc. (IISI), MGU on behalf of QBE Insurance Company and American National Life Insurance Company of Texas
J. Allan Hall & Associates, Inc., MGU on behalf of their underwriting facility, Lloyd's of London
National Benefit Resources, MGU on behalf of UnitedHealth Group insurance companies
R. E. Moulton, Inc. / American United Life Insurance Company (OneAmerica Companies)
RMTS, LLC, MGU on behalf of their carriers Nationwide Life Insurance Company, Gerber Life Insurance Company, and Trustmark Insurance Company (as filed)
StarLine Group, MGU on behalf of QBE Insurance Company, Nationwide Life Insurance Company and Lloyd's of London.
Stop-Loss Concepts, Inc., MGU on behalf of their carriers, Gerber Life Insurance Company and QBE Insurance Company.
Latest Survey Results Recommending Adoption
Respondents from the self-funded community have voted 86% in favor of adoption of the standard form for Stop-Loss disclosure. For all survey results, see www.MyHealthGuide.com/disclosures.htm.
Standard Form Adoption May Not Mean Standardization
While surveyed members (n=112) from the self-funded community voted 86% in favor of adoption of the standard form for Stop-Loss disclosure and a majority of the Stop-Loss market has adopted the form, complete standardization is still a goal.
LaRea Albert of Health First TPA (Tyler, TX ) complains, "The Standard Stop-Loss Employer Disclosure Form is not standard, we are getting a different standard from various MGUs and carriers." Another colleague at Health First, said, "Each Stop-Loss source requires enough 'extras' that Health First concludes the form should not be called, "Standard."
"These comments show that, at least down
at the operating level, many underwriters and their managers
'do not get it'! If the form is 'approved', but insist on
the unique information carrier by carrier, then that's not
accepting the standard, " says John Lord, Vice
President-Specialty Zurich Specialty Health, and a member of
the Industry Study Group which developed the Standard
Disclosure Form. "Clearly we have work to do to get
the message out to all the right people."
Disclosure Form, Codes, White Paper, Available
The following draft documents may be downloaded and viewed at www.myhealthguide.com/disclosures.htm.
Standard Disclosure Form & Codes (with instructions) Word Format
Standard Disclosure Form & Codes (with instructions) Acrobat PDF Format
Stop-Loss/Reinsurance Disclosure & Reporting "White Paper" (updated 9/1/2006)
About Employer Disclosure
The Employer Disclosure, required by most Stop-Loss carriers and MGUs, has grown in sophistication and use. Today, most Stop-Loss sources require an employer disclosure before a new or renewal quote is offered. Ideally, the Employer Disclosure lists all known high cost claims, claims that have exceed a given dollar threshold, or patient/employees with certain diagnoses. Failure to disclose these individuals can later lead to claim denials. For the past several years, an industry study group has worked on "standardizing" the reporting process with the objective that all insurers would come to accept the reporting system/form as an industry standard.
July 7, 2009
WEDI HL7 Claims Attachments Audiocast:
Getting to Know Claims Attachments: The Fundamentals of the X12,
Health Level Seven (HL7) and LOINC Standards presented by
Workgroup for Electronic Data Interchange (WEDI). Introductory look at the claims attachments
standards expected to be named under HIPAA. You'll learn how the X12 277 and 275 work with
the HL7 CDA and how the LOINC codes work to tie everything together.
Speakers: Laurie Burckhardt, WEDI SNIP Transaction Code Set Co-chair; ASC X12N Work
Group 2 (Claims) Co-chair, Moderator; Wes Rishel, Past Co-chair HL7 Attachments Work Group; VP/Distinguished
Analyst, Gartner, Inc.; Mary Lynn Bushman, WEDI SNIP Claims Attachments Subworkgroup Co-chair; ASC
X12N Work Group 9 (Claims Attachments) Co-chair Registration:
http://wedi.org/forms/meeting/MeetingFormPublic/view?id=B4F7000000E6.
www.wedi.org
July 15-17, 2009
HCAA TPA University 2009 presented by Health Care Administrators
Association .
Disney Grand Californian, Anaheim, CA. Contact Jaime Nolan, CAE, Executive Director, Health Care Administrators
Association, (888) 637-1605, jnolan@hcaa.org
and visit www.hcaa.org
July 21-22, 2009
Extraordinary Innovations in Transplantation and Oncology,
A complimentary accredited conference provided by OptumHealth and The Nebraska Medical Center.
Clinical experts share novel techniques and unique, innovative services in
the areas of oncology and solid organ and blood/marrow transplantation
including:
Omaha, Nebraska. Information: http://attendesource.com/profile/web/index.cfm?PKwebID=0x36496530. Registration: http://attendesource.com/profile/web/index.cfm?PKwebID=0x3668b6bc&varPage=location.
July 21-23, 2009
MCIA Annual Conference Program presented by Montana Captive Insurance
Association, Inc. (MCIA). Features
11 relevant educational sessions and several networking events, including a
white water rafting trip.
Recently-elected Insurance Commissioner Monica Lindeen will lead off the
educational program sharing thoughts on the state’ growing s captive insurance
sector. Whitefish, Montana. Information and registration: Justin Miller,
866-388-6242, jmiller@mtcaptives.org
and visit www.mtcaptives.org.
August 11-13, 2009
Vermont Captive Association
Annual Conference.
Sheraton,
Burlington, VT. www.vcia.com
September 21-24, 2009
29th Annual National Educational Conference & Expo presented by
Self-Insurance Institute of America. World's largest event dedicated
exclusively to the self-insurance / alternative risk transfer industry.
Highlights:
Registrants will enjoy other cutting-edge educational offerings combined with unique networking opportunities, and a world-class tradeshow of industry product and service providers guaranteed to provide exceptional value in four fast-paced, activity-packed days. Marriott Worldcenter Hotel • Orlando, FL. www.SIIA.org
October 5-7, 2009
SPBA Fall 2009 Meeting - Members Only presented by
Society of Professional Benefit Administrators. Portland, OR.
www.SPBATPA.org
October 25-28, 2009
Medical Tourism Association.
World Medical Tourism Conference. Hyatt Century Plaza.
Los Angeles.
www.medicaltourismassociation.com
November 16-19, 2009
WEDI Fall Conference presented by Workgroup for Data
Interchange (WEDI). Renaissance Harborplace Hotel.
Baltimore, MD. Registration and information: Patti Brown at (703)
391-2717 and pbrown@wedi.org and
www.WEDI.org
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: MyHealthGuide is associated with CareHere, LLC® and LabInsight®.
Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
Clevenger@MyHealthGuide.com