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TABLE OF CONTENTS
6 Degrees Health Adds University of Washington to Transplant Network
MyHealthGuide Source: 6 Degrees Health, Inc., 10/17/2014, www.6degreeshealth.com
Beaverton, OR -- 6 Degrees Health is pleased to announce the addition of the University of Washington to its exclusive group of transplant and complex care hospitals: OURproviders™.
The University of Washington is the highest volume transplant facility in the Northwest boasting outcomes you would expect from a high-end academic medical institution. The only lung transplant program north of San Francisco on the West Coast, the University of Washington is an important destination for 6 Degrees' patients in Oregon, Washington, Alaska, Idaho and surrounding states.
"The University of Washington is a destination transplant facility with comprehensive abdominal and cardiothoracic transplant programs. 6 Degrees filled a critical gap in our network by adding the University to our exclusive group of exceptional transplant hospitals," states Scott Ray, 6 Degrees Health's CEO.
About 6 Degrees Health, Inc.
6 Degrees Health is a Specialty Network focusing on mitigating the risks with transplants, cancer, cardiac and other complex high-dollar care. OURsolutions™ is designed for Insurers, Third Party Administrators, Stop Loss and Reinsurance carriers, Self-Insured Employee Health Plans, Health Maintenance Organizations, and Government Health Plans. OURsolutions™ promotes improved patient outcomes, optimizes Payor savings, and delivers the incremental volume to OURproviders™. The keystone of 6 Degrees Health's solutions is its proprietary analytics platform (VeritasDx™) … there is no equal in the market executing the transparency necessary to achieve a win-win for Patient, Payor and Provider. Contact David Vizzini, President, 6 Degrees Health, Inc., at firstname.lastname@example.org, 503-640-9933 ext. 102 and visit www.6degreeshealth.com.
Custom Design Benefits Presents TrueCost Referenced-based Pricing at Conference
MyHealthGuide Source: Custom Design Benefits, 9/10/2014, www.customdesignbenefits.com and CDB Presentation
Custom Design Benefits, Cincinnati's largest independent third party administrator of health benefit plans, held its 7th annual customer conference to present innovative cost containment solutions for employee benefits on September 10, 2014. Attendance at this year's conference grew by 30% to over 180 representatives from local employers and health benefit advisory firms. Assisting clients to provide their employees with affordable health benefits and complying with the new and future Affordable Care Act regulations were key topics at the conference.
The conference was held at Cincinnati's Horseshoe Casino, so the theme "in today's healthcare environment, you need more than luck" was particularly appropriate.
TrueCost Reference-based Formula Highlighted
TrueCost, a self-funded health plan built upon a reference-based payment formula, was highlighted as one of the most effective strategies for employers to contain and control the cost of their health benefits. Introduced into the Cincinnati market by Custom Design Benefits in 2011, TrueCost offers employers a simple payment structure in which health provider reimbursements are based on fixed Medicare pricing plus a set percentage. "Using a reference based pricing model is consistent, rational and transparent," said Julie Mueller, president of Custom Design Benefits. "With TrueCost, employers can offer their employees simple plan designs with richer benefits without networks or deductibles or coinsurance."
Healthcare providers routinely accept Medicare, which bases its reimbursement on actual costs plus a reasonable profit margin, In the case of TrueCost, Medicare is used as the reference price plus an additional provider bonus. TrueCost has caught on with many local healthcare providers that have embraced its simplified and efficient reimbursement system. Local employers are using High Deductible health plans more and more as a strategy to contain healthcare costs. As a result, employees are now responsible for paying a much larger portion of their medical costs. As a result, health providers face the additional challenge of collecting the employee portion of the bill and a collection rate of less than 20% of the amount owed is not unusual.
Working with Custom Design Benefits as the plan administrator, providers that accept TrueCost receive prompt and predictable reimbursements without having to absorb the additional cost of collection efforts.
Reference-based Pricing Saves Average 62%
Since launching TrueCost, Custom Design Benefits tracked the actual savings of healthcare claims compared to those within a traditional PPO network. While traditional PPO networks were able to provide a discount on billed charges that ranged between 23% and 46%, TrueCost clients took advantage of reference-based pricing and realized an average savings of 62%.
Employers offering a TrueCost plan are in a more competitive position to stabilize their healthcare costs while offering their employees simplified plans with no deductibles or coinsurance -- just copays.
Direct contracts between hospital systems and employers has been a natural progression of Custom Design Benefits' TrueCost, and has been embraced by forward thinking hospital systems in Cincinnati that include TriHealth, St. Elizabeth and The Christ Hospital. By contracting directly with hospital systems and their provider networks, employers are able to eliminate the challenges and problems associated with secret contracts between insurance companies' PPO networks and hospitals. With no middle-man, hospital systems are now able to compete directly for employer contracts. This competition benefits employers and employees through higher quality of care at more affordable costs.
A panel of executives from TriHealth, St. Elizabeth and The Christ Hospital shared their insights and their organizations' future strategies with Custom Design Benefits clients and health
benefit advisors at the Customer Conference.
"Right now, we're in the sick-care business instead of the healthcare business," said Jacob
Bast, Senior Vice President & COO at St. Elizabeth Physicians. "We want to collaborate with our local employers to align incentives focused on improving early access, quality and reduced costs."
John Sunde, Vice President of Managed Care at TriHealth said, "As an integrated delivery system, TriHealth has worked very hard to create an infrastructure and environment where we operate as a team, with common expectations, goals and rewards. This will position our providers and the health system to take on higher levels of accountability to effectively manage broader populations."
In 2013, TriHealth and St. Elizabeth announced a joint venture, Healthcare Solutions Network, that will share resources and expertise with the goal of improving quality and customer experience, lowering cost and improving affordability, and improving population health.
"We cannot continue to rely on our current healthcare delivery models and expect to see any improvement in containing costs or improving outcomes", said Timothy Cappel, Executive Director of Population Health at The Christ Hospital. "Our vision is to be a national leader in clinical excellence, patient experience and affordable care." Cappel outlined recent initiatives such as The Christ Hospital Health Network that address services provided, delivery channels and patient experience. "Through our Centers of Excellence, we coordinate our patients through their entire experience, are able to offer simplified plan designs and costs, and offer a warranty that assures high quality work," said Cappel.
All three hospital systems addressed the evolution in the current fee-for-service model that
have led to healthcare providers contracting directly with employers.
"TrueCost is a game-changer in how employers pay for healthcare," said Mueller. "It's the
only plan out there that actually drives any sort of consumerism at all and has allowed our
clients to be much more proactive with their healthcare.
About Custom Design Benefits
Custom Design Benefits delivers exceptional customer service and cost effective solutions to brokers and their clients by offering tailored employee benefits administration services including: Self-Funded Health Benefits, Wellness Solutions, Compliance Solutions, Cost Management Solutions, Consumer Driven Solutions and High Deductible Health Plans.
Custom Design Benefits currently distributes TrueCost through a select group of preferred
brokers and advisors. Contact Custom Design Benefits at 513-598-2900 and visit www.customdesignbenefits.com.
HealthCare Information Security and Privacy Practitioner (HCISPP) Training -- Nashville, December 1-3
MyHealthGuide Source: Clearwater Compliance, 10/13/2014, www.clearwatercompliance.com
Clearwater Compliance announces their HealthCare Information Security and Privacy Practitioner (HCISPP) Training in Nashville, TN scheduled December 1-3, 2014.
This official HCISPP training seminar is the most comprehensive, complete review of healthcare security and privacy concepts and industry best practices. The training specifically covers each element of the HCISPP common body of knowledge (CBK®), including foundational information on:
• The Healthcare Industry
• The Regulatory Environment
• Privacy and Security in Healthcare
• Information Governance and Risk Management
• Information Risk Assessment
• Third Party Risk Management
"If you're preparing for HCISPP, this is a can't miss resource to get you ready," said Bob Chaput, CEO and founder of Clearwater Compliance. "We are honored to be a trusted training partner with (ISC)² and we're excited to help a new crop of security and privacy practitioners take the next step in achieving certification."
Cost of the Clearwater HCISPP training is $1,595.
About Clearwater Compliance
Clearwater Compliance, LLC. is all about and only about HIPAA Compliance. We are a boutique software and services company helping health care organizations and their service providers become and/or remain HIPAA-HITECH compliant. Using the Privacy, Security and Breach Notification regulations as a foundation, supplemented with the Office for Civil Rights (OCR) Audit Protocols and the NIST Security Framework, all solutions are regularly updated to reflect the very latest regulatory requirements, HHS/OCR Settlement Agreements and other legal precedents. Contact Helene Cuddeback, Marketing Assistant, at 615-913-4510, email@example.com and visit www.clearwatercompliance.com.
ECHO Receives Weatherhead 100 Award for 2nd Consecutive Year
MyHealthGuide Source: ECHO Health, Inc., 10/16/2014, www.echohealthinc.com
Westlake, OH -- ECHO Health, Inc. was recently presented with a 2014 Case Western Reserve University Weatherhead 100 award, which recognizes the fastest growing 100 companies in Northeast Ohio. Requirements for the award include total net sales of at least $100,000 in 2009, more than $1 million in net sales last year, and a minimum of 16 full-time employees.
"Receiving this prestigious award for the second consecutive year marks our team's commitment to making ECHO the top payment solutions provider in the healthcare industry," said William Davis, ECHO Chairman of the Board and CEO. "We are proud of this honor and will continue to strive to deliver excellence for each of our customers."
About ECHO Health, Inc.
ECHO Health, Inc. is a leading provider of electronic healthcare payment solutions. Serving more than 50,000 ERISA health plans and fully insured groups, ECHO processes more than $10 billion in payments annually to providers and members through industry-leading payers. Founded in 1997, ECHO is a privately held company located in Westlake, Ohio. Call 440.835.3511, ext. 123, and visit www.echohealthinc.com.
QBE North America Appoints Hy Pomerance, Chief Human Resources Officer
MyHealthGuide Source: QBE North America, 10/13/2014, www.qbena.com
New York, NY -- QBE North America has announced the appointment of a new Chief Human Resources Officer, Hy Pomerance.
With over 18 years experience aligning business strategy with HR programs, Pomerance's unique background will provide the kind of strong, stable leadership ideal for a dynamic business like QBE.
"As we continue to transform QBE North America, it will be of particular benefit to have Hy's managing the people part of our organization," says Dave Duclos, President and CEO.
Pomerance's impressive credentials include senior HR roles at Arcadis and UBS Bank. Pomerance also served as the SVP, Chief HR Officer at The New York Life Insurance Company, and has provided consultancy services to a number of leading national and global organizations. He is a graduate of Yeshiva University, and holds a Masters in Organizational Behavior and a Doctorate in Psychology.
Driving the company's people and talent strategies will be a priority for Pomerance when he joins QBE on October 13. Based in the New York City office, he will report directly to Dave Duclos.
QBE North America is part of QBE Insurance Group Limited, one of the largest insurers and reinsurers worldwide. QBE NA reported Gross Written Premiums in 2013 of $5.855 billion. QBE Insurance Group's 2013 results can be found at www.qbena.com. Headquartered in Sydney, Australia, QBE operates out of 43 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New York, conducts business through its property and casualty insurance subsidiaries. QBE insurance companies are rated "A" (Excellent) by A.M. Best and "A+" by Standard & Poor's. Visit www.qbena.com.
One Call Care Names Greg Roth to Board of Directors
MyHealthGuide Source: One Call Care Management, 10/14/2014, www.onecallcm.com
JACKSONVILLE, FL -- One Call Care Management (One Call), the nation's leading provider of specialized services that add value throughout the continuum of workers' compensation care, has named healthcare executive Greg Roth to its Board of Directors.
"Greg's experience as a leader and innovator in healthcare will be a tremendous asset to One Call's Board of Directors and to our leadership team," stated Buddy Gumina, Partner with Apax Partners and Chairman of One Call Care Management.
"As One Call moves forward in its mission to improve workers' compensation outcomes by delivering market-leading specialty services, innovative leakage capture solutions, and enhancing efficiencies across the continuum of care, Greg's insights and leadership will be a welcome addition," commented Joe Delaney, President and CEO of One Call.
"One Call brings an inspiring vision to workers' compensation combined with the commitment to deliver on what customers need today while innovating for their needs tomorrow," observed Mr. Roth. "It is the first and only company to bring together the industry's top experts in specialty services across the continuum of care, along with the financial strength and stability to truly transform workers' compensation results. I look forward to being a part of One Call's journey toward that vision."
Mr. Roth's career spans three decades of introducing innovation to transform and improve healthcare. Most recently he spent 10 years with TeamHealth, a leading national healthcare company offering permanent outsourced physician staffing solutions for 860 healthcare companies in 46 states. At TeamHealth, Mr. Roth held the positions of Chief Executive Officer, President and Chief Operating Officer, and also served as a member of the Board.
Previously, Mr. Roth served as an executive for HCA - Hospital Corporation of America for 10 years as President of the Ambulatory Surgery Division, Senior Vice President of Operations for the Western Region, and the Division's Chief Financial Officer.
Prior to these leadership roles, Mr. Roth held a variety of financial and operational positions in the healthcare industry. He holds a Master's Degree in Health and Hospital Administration from Xavier University and a B.S. in Allied Health Professions from Ohio State University. He is a Certified Public Account (CPA) and a Registered Respiratory Therapist.
About One Call Care Management
One Call Care Management (One Call) is the nation's leading provider of specialized solutions to the workers' compensation industry. One Call's solutions enable faster, more efficient and more cost-effective claims resolution. One Call provides reliable, consistent connections to care with expertise in high end diagnostics, physical therapy and transportation services, post-discharge home care and durable medical equipment, dental and doctor specialty services, complex care management, and the language services required for today's multicultural workforce. With a focus on injured workers' needs across the continuum of care, One Call enables maximum medical improvement and superior outcomes. Visit www.onecallcm.com.
United Claim Solutions (UCS) Welcomes Mark Wild as Regional Sales Manager for the Western Region
MyHealthGuide Source: United Claim Solutions (UCS), 10/17/2014, www.unitedclaimsolutions.com
PHOENIX, AZ -- United Claim Solutions (UCS), an innovative Medical Cost Reduction and Claims Flow Management firm has hired Mark Wild to manage its sales efforts in the west.
"We are pleased to announce the addition of Mark Wild as our newest Regional Sales Manager. Mark has a track record of success selling cost-containment services and brings a broad range of skills and experience to UCS. We anticipate that Mark will enable us to continue our strong growth into 2015 and beyond", said Corte Iarossi, VP of Sales & Marketing.
United Claim Solutions is an innovative Medical Cost Reduction and Claims Flow Management company providing cutting edge and customizable programs for payers, employers, unions, reinsurers, accountable care organizations and health plans. UCS offers end to end services including Bill Review, Out-of-Network Bill Repricing, Specialty Negotiations, Bill Edits, Medicare Repricing, PPO Administration, Medical Management, Clearinghouse Services, Data Warehousing, OCR/Scanning, and Plan Modeling. We provide solutions for Group Health, Workers' Compensation, and Auto Liability. Contact UCS if you are looking for:
• A partner that puts Service first
• Industry leading Savings on medical bills
• Flexible Solutions that reduce administrative costs
For more information contact Corte Iarossi, VP of Sales & Marketing at 866-762-4455 x 120, or via email at firstname.lastname@example.org and visit www.unitedclaimsolutions.com.
Advanced Medical Strategies (AMS) Announces David Boucher as Vice President of Business Development
MyHealthGuide Source: Advanced Medical Strategies (AMS), 10/15/2014, www.mdstrat.com
Advanced Medical Strategies (AMS) is very proud to announce its newest addition to the team, David Boucher as Vice President of Business Development. David brings 16 years of experience in the employee benefits industry.
We are confident that David, a former partner of Longfellow Benefits in Boston, will put his considerable expertise in business growth and leadership to good use here at AMS.
"I've personally known David the last 15 years," said Peter Borans, AMS President, "and his stature in the broker and insurance community will be critical to our roll-out of a new suite of information tools for brokers. When we discussed the impact that products like PredictDx and PredictRx can have within the brokerage community, David couldn't wait to begin broadening our reach and identify new opportunities in the key markets we serve".
AMS is very happy to have David on board and is looking forward to seeing where he can take AMS and the PredictDx and PredictRx products.
Advanced Medical Strategies is a physician-lead organization bringing innovative solutions to the health care payor industry. Based in Lynnfield, MA, Advanced Medical Strategies has been offering world-class claims review and cost containment services since 2003. To view a video demonstration of PredictDx, visit www.mdstrat.com/ams-unveils-predictdx. For more information, or to schedule a demo, please call Danae Lambeth, National Sales Director at (781)-224-9711 x107, email@example.com and visit www.mdstrat.com.
Lockton Adds Peter Rapciewicz as Captives, Risk Finance, Alternative Risk Expert
MyHealthGuide Source: Lockton via PRNewswire, 10/8/2014, www.lockton.com
NEW YORK-- Peter Rapciewicz has joined Lockton, the world's largest privately held, independent insurance broker, as a vice president in their Risk Finance Practice in New York City. He brings more than 11 years of experience in alternative collateral structures, captive insurance programs, and large casualty programs.
In his role, Rapciewicz will provide strategic consultation and implementation on program design, collateral strategies, captive consultation, and alternative risk programs for clients across the country. He will also lead new initiatives in the use of alternative collateral vehicles.
"We are excited to add Peter's expertise to the team in New York," said Lisa Wall, Risk Finance Practice Leader for Lockton. "He has developed and implemented captive and alternative collateral structures for a wide range of clients. He has led in the development and structuring of loss sensitive casualty programs."
Rapciewicz comes to Lockton from AIG where he most recently served as Vice President of the Alternative Risk Division. He holds a Bachelor of Science degree in Business Administration from Susquehanna University.
More than 5,300 professionals at Lockton provide 41,000 clients around the world with risk management, insurance, and employee benefits consulting services that improve their businesses. From its founding in 1966 in Kansas City, Missouri, Lockton has attracted entrepreneurial professionals who have driven its growth to become the largest privately held, independent insurance broker in the world and 9th largest overall. Independent researcher Greenwich Associates has awarded Lockton its Service Excellence Award for risk management for large companies. For six consecutive years, Business Insurance has recognized Lockton as a "Best Place to Work in Insurance." Visit www.lockton.com.
When is a Workers' Comp Claim
When other medical conditions affect treatment options, recovery
times and the cost of the claim.
These findings were expanded in research conducted by the National
Council on Compensation (NCCI), which paired claims of workers with
obesity as a secondary diagnosis with claims of workers with
virtually identical characteristics but no obesity diagnosis. The
study, which included a larger number and more industry-diverse
claims than the Duke study, found that medical costs for claims of
obese workers were not only greater -- in this study three times as
large 12 months after the date of injury -- as non-obese workers, but
the cost difference also grew over time. After 36 months, cost of
claims with an obesity diagnosis was four times larger than that for
other claims, and after five years, the difference was a multiple of
five. The California Workers' Compensation Institute also examined
this issue, analyzing claims from 2005 to 2010. Their study found
that average benefit payments on claims for employees with obesity
as a comorbidity were 81% higher than those without.
According to the NCCI study, claims with a comorbidity diagnosis are also more likely to have a lost-time cost component. The most striking difference occurred in claims with an obesity diagnosis.
Comorbidities can Stall Recovery
What the numbers don't explain are the ways in which comorbidities
can stall recovery. They don't tell of hard-to-heal wounds because
of decreased blood supply in workers with diabetes, the increased
risk of post-surgical complications stemming from hypertension, the
continued pain from non-union of a fractured bone in smokers, the
risks involved from taking multiple medications from different
providers or the higher healing threshold for obese workers whose
sprains or strains need to heal beyond the point required of a
healthy weighty worker in order to support the added weight.
The Silver Tsunami Hits the U.S. Workforce
The risk of co-morbidities, particularly hypertension, diabetes and to some extent obesity, increases with age. This trend could have a multiplier effect on workers' compensation costs for many employers that have started to see their workforce grow older.
And Americans are working beyond the traditional age of retirement.
According to the Insurance Information Institute, one of every three
Americans age 65 to 69 and one out of every five Americans are 70 to
74 are employed. These numbers are expected to grow, expanding the
ranks of workers who are at greater risk of developing
comorbidities. The impact of these medical conditions is likely to
have a greater impact on workers' compensation costs, unless
something is done.
Identifying and Managing Claims With Comorbidities
Many employers are offering programs or incentives, such as lower
healthcare premiums, to encourage employees to adopt a healthier
lifestyle or improve fitness over the long term (e.g., quit smoking,
lose weight, exercise more). Certainly reducing comorbidities can
have a positive impact on claims costs, but it is unlikely that
comorbidities will be eliminated. So when a work-related injury or
illness strikes an employee with an underlying medical condition,
developing a strategy that targets a comorbidity can be the
difference between a long and costly road to partial recovery and a
steady return to health.
"At other times, it's important to separate treatment for the
comorbidity from treatment of the workplace injury or illness,"
cautions Hebert. "For
example, paying for insulin during surgery for a workplace injury
would likely be appropriate, but it may be questionable to pay for
it under workers' compensation once the surgery is completed and
blood levels continue to fluctuate for reasons unrelated to the
WellComp has been a leading national provider of managed care services. We’ve specialized in Workers’ Compensation cost containment since 1985, and our team has the experience and expertise to create and manage custom solutions that deliver cost savings to clients and the appropriate care to injured workers. Our processes are URAC accredited and many of our 350 employees are certified specialists in their areas. Visit www.wellcomp.com.
Group Captives Help Firms Tackle Health Benefits Funding Issues
MyHealthGuide Source: Joanne Wojcik, 10/18/2014, Business Insurance Captive Article
Mid-market companies are discovering that group captives can make self-funding employee health benefits a bit less daunting, experts say.
Captives can provide a primary layer of medical stop-loss coverage that would be tapped before traditional stop-loss insurance. Because medical stop-loss coverage purchased at higher attachment points generally is less expensive than that with lower attachment points, it could save the employer money while also providing protection from high-cost claims.
Captives Help Reduce Risk of Lasers
Self-funded employers that use a group captive for primary stop-loss coverage also can avoid "lasering," a practice in which insurers set higher attachment points for certain plan members with costly pre-existing conditions.
"Small employers tend to find that self-funding is more of a risk because of the lasers," said Kenneth R. Olson, president of Horton Benefit Solutions in Chicago. "They can be absolutely devastating for businesses' financial statements. So we've tried to craft the captive concept to provide reinsurance net of stop-loss."
For example, if 10 companies each with 50 to 500 employees form a group captive to provide stop-loss coverage at attachment points up to $500,000, they most likely never will feel the impact of a laser, Mr. Olson said.
"Most lasers come in about $100,000 to $200,000. We almost never hear of a laser above $500,000," he said.
To protect the captive from being hit with a sizable claim that would otherwise be subject to a laser, the captive can purchase disease-specific coverage, said Mr. Olson.
"We require all our members to buy first-dollar transplant coverage," he said. "It is relatively inexpensive. For a group with 100 lives, you might spend less than $10,000 a year."
But the peace of mind it provides to all employers participating in the captive is priceless, Mr. Olson said.
"If you have one transplant in your group, you're looking at several hundred thousand dollars. If this person is put on a transplant waiting list, there is an automatic laser. But with the transplant cover, there is no laser," he said.
Captives Help to Ease into Self-Funding
"If you take a look at the market, many midsize employers chose not to self-insure because they were concerned about large swings in cost," said Sam Fleet, president of Charlotte, N.C.-based AmWINS Group Inc. "For them to go self-insured, it takes a huge leap of faith. They don't get any data from their carriers," so they don't know how much risk they may be taking on.
But for group captives funding medical stop-loss coverage, "it's a brave new world. It's becoming one of the more popular ways to self-fund health benefits," Mr. Fleet said.
The high cost of health care combined with the federal health care reform law is driving interest among mid-market companies in using captives for health benefits self-funding, said Rick Stasi, chief operating officer of the alternative risk division at Avizent in Dublin, Ohio.
"They say, "You've done a good job controlling our property/casualty costs, but we're getting clobbered on health insurance,'" he said.
On a related front, some protected cell captives that Avizent manages have been providing stop-loss coverage for about two years, he said. In fact, Avizent itself is a participant, using a captive to fund stop-loss coverage of its self-funded benefits program for less than 1,000 employees, Mr. Stasi said.
"The captive takes anywhere from $25,000 to $250,000," depending on where the participating employer wants its stop-loss attachment point to be, and New York-based Chartis Inc. picks up any claims above that amount, Mr. Stasi said.
Like group captives that self-insure liability risks, virtually all of these new benefits captives require participating employers to engage in certain loss-control activities, such as health risk assessments and population health management, experts said.
For example, the captive the Horton Group is assembling, which will be managed by Berkley Accident & Health L.L.C., a unit of Greenwich, Conn.-based W.R. Berkley Corp., is requiring that 80% of the employees of participating employers complete a health risk assessment as a condition of remaining in the captive.
Because many participating employers previously did not have an incentive to offer wellness programs because their insurers did not give them credit against their premiums for engaging employees, "it's exciting for us to do population health management for the first time for many of these employers/ groups," Mr. Olson said. "We expect a culture shift."
"The benefit of the captive is not necessarily risk sharing, but health risk management," said Mr. Fleet. "The objective is to become a zero-trend company. You can do that when you have a group of employers together that have the same goal and objectives."
Implementing Health Reform: Reference Pricing And Network Adequacy
MyHealthGuide Source: Timothy Jost, 10/12/2014, Health Affairs Article
Editor's Note: Mr. Jost is scheduled to present at the HCAA’s Executive Forum 2015schedules February 9 - 11, 2015. His topic is "Will the Long Term Impact of ACA Expand or Shrink Self Funding?"
On October 10, 2014, the Departments of Labor, Treasury, and Health and Human Services issued a frequently asked question (FAQ) regarding the use of reference-based pricing in non-grandfathered large group employer plans. Although the issue the FAQ addresses specifically is the use of reference pricing, the FAQ is remarkable insofar as it is the first departmental guidance that I am aware of that addresses the use of networks by self-insured ERISA plans.
Network adequacy is an issue that has long been addressed in the nongroup and insured group market in many states by state insurance law. The ACA also requires qualified health plans, and arguably any individual and small group plan subject to the essential health benefits requirements, to have adequate provider networks. Special rules implementing ACA section 2719A of the ACA limit cost-sharing for out-of-network coverage for emergency services.
The departments also stated in an earlier FAQ that cost sharing cannot be applied by any non-grandfathered health plan for preventive services provided by out-of-network providers if the services are not available in network. But I am unaware of the departments otherwise attempting previously to regulate group health plan network requirements, at least under the ACA.
Section 2707(b) of the ACA applies section 1302(c) of the law to large- and small-group health plans. Section 1302(c) imposes an annual maximum on out-of-pocket costs on non-grandfathered group plans, which for 2015 is $6,600 for self-only coverage and $13,200 for non-self-only (family) coverage. Cost-sharing does not, however, under 1302(c) include "balance-billing amounts for non-network providers." The HHS rules interprets this provision more broadly to not require health plans to count toward the out-of-pocket limits any cost sharing paid by, or on behalf of, an enrollee for out of network benefits. The departments adopted this provision as well in an earlier FAQ for all group plans.
The goal of reference-based pricing is to allow plans to negotiate prices with high-quality providers and to encourage plan participants and beneficiaries to use those providers. A health plan offers a fixed amount which certain providers will accept as payment for a particular procedure. Plan participants and beneficiaries who use a provider that does not accept the reference price must pay the difference between the provider's charge and the reference price out of pocket. These out-of-pocket payments do not count toward the statutory maximum out-of-pocket limits.
This presents a problem, however, if plan participants and beneficiaries are not able to access adequate services without exceeding the statutory out-of-pocket maximum. Reference-based pricing could serve as a subterfuge for imposing otherwise prohibited out-of-pocket costs on plan participants and beneficiaries.
The departments released an FAQ in May stating that they would not consider a plan out of compliance with the maximum out-of-pocket requirement, "provided the plan uses a reasonable method to ensure that it provides adequate access to quality providers." They also asked for comments on how reference-based plans should be regulated.
What's In The New Guidance?
The October 10 guidance states that the departments will "consider all the facts and circumstances when evaluating whether a plan's reference-based pricing design . . . that treats providers that accept the reference-based price as the only in-network providers and excludes or limits cost-sharing for services rendered by other providers is using a reasonable method to ensure adequate access to quality providers at the reference price . . . ."
Plans must have standards to ensure that the network is designed to offer high-quality providers at reduced costs and not serve as a subterfuge to evade the maximum out-of-pocket limitation. Pricing that treats providers that accept reference prices as the only in-network providers must do so only for services where there is sufficient time between when the need is identified and when the service is provided to allow the consumer to make an informed choice of provider. In particular limiting or excluding cost-sharing for providers who do not accept the reference price is not permitted for emergency services. This would be independently prohibited by the ACA, as noted above.
Plans must also ensure that an adequate number of providers that accept the reference price are available to plan participants and beneficiaries. In determining adequacy, plans should consider approaches developed by the states, including geographic distance standards and whether wait times are reasonable. Insured group plans are, of course, independently subject to applicable state network adequacy regulations. Plans should also ensure that an adequate number of providers are available that meet reasonable quality standards.
Plans should have available an easily accessible exceptions process that permits participants and beneficiaries to use providers that do not accept the reference price if providers that accept the price are not available within a reasonable wait time or in a reasonable distance, or if adequate quality care is not available for a particular individual -- for example because of co-morbidities or patient safety issues.
Finally, plans must provide automatically, through the summary plan description or similar document, information on the pricing structure, including a list of services to which the pricing structure applies and a description of the exceptions process. On request, the plan should provide a list of providers that will accept the reference price or a negotiated price above the reference price for each service, as well as "information on the process and underlying data used to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards." No disclosure is required from providers, however, at point of service, when it would be much more helpful.
Broadly Applicable Reasoning
Although the FAQ is aimed specifically at reference-based pricing, it describes reference-based pricing as a kind of network design and extends the FAQ to "similar network design[s]." The reasoning behind it would in fact seem to apply to any network. In any situation where a plan network does not offer accessible providers of adequate quality, plan participants and beneficiaries risk having to pay excessive out-of-pocket costs. And any time a plan is self-insured it is not subject to state regulation or indeed to any regulation unless the departments assert regulatory authority.
Reference-based pricing plans are relatively new, and the departments presumably concluded that it would be advisable to assert their authority from the beginning. But some form of regulation for network plans generally can and should follow.
The FAQ concludes by stating that the agencies will continue to monitor the use of reference-based pricing and may provide further guidance in the future, including guidance regarding additional requirements that apply to individual and small group essential benefit plans. But more guidance regarding networks for ERISA plans generally is also needed.
Federal Agencies Take Steps Toward Regulating Reference-Based Pricing
MyHealthGuide Source: Self-Insurance Institute of America, 10/16/2014, www.SIIA.org
The Departments of Treasury, Labor, and Health and Human Services (the "Federal Agencies") last week took one more step toward regulating reference-based pricing utilized by self-insured plans. In a Frequently Asked Question ("FAQ"), the Federal Agencies put parameters around what type of reference-based pricing structures would be considered "reasonable" for purposes of complying with the new out-of-pocket ("OOP") maximum limitation set forth under the Patient Protection and Affordable Care Act ("ACA").
In a previous FAQ (released on May 2, 2014), the Federal Agencies provided some flexibility as it relates to the use of reference-based pricing in self-insured plans. In that FAQ, the Federal Agencies indicated that amounts in excess of the reference price would not be counted toward the OOP maximum limitation, provided the plan uses a reasonable method to ensure that it offers adequate access to quality providers. In the FAQ issued last Friday, the Federal Agencies clarified what would be considered "reasonable."
According to the FAQ, the use of reference-based pricing would be reasonable only if there is sufficient time between when the need for care is identified and when the service is provided to allow the consumer to make an informed choice of provider. If this standard is not met, then the plan must count any out-of-pocket payments toward the OOP maximum limits. In addition, limiting or excluding out-of-pocket payments for providers that do not accept the reference price in the case of emergency services is unreasonable. In other words, out-of-pocket spending in cases of emergency services must be counted toward the OOP maximum, period.
The Federal Agencies also require that self-insured plans make available to participants and beneficiaries an adequate number of providers that accept the reference price, and the FAQ suggests that self-insured plans must follow the "network adequacy" rules applicable to fully-insured individual and small group plans (which include rules for determining whether wait times are reasonable as well as reasonable geographic distance measures).
Self-insured plans must also have procedures to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards, and in cases where access to a provider that accepts the reference price is unavailable - or the quality of services could be compromised with the reference price provider - the plan must count the amounts paid for the medical services up to the reference price toward the OOP maximum limits (i.e., the services performed by the provider that does not accept the reference price cannot be treated as out-of-network services).
Finally, in a nod to consumer advocates, self-insured plans must automatically provide information regarding pricing structures, including a list of services to which the reference-based pricing structures apply. The plan must also provide to a participant or beneficiary - upon their request - (1) a list of providers that will accept the reference price for specific services, (2) a list of providers that will accept a negotiated price above the reference price for each service, and (3) information on the process and underlying data used to ensure that an adequate number of providers accepting the reference price meet reasonable quality standards.
he 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.
EBSA Chief Accountant: Hire the Right Auditor to Avoid DOL audits
MyHealthGuide Source: Michael Giardina, 10/14/2014, Employer Benefit News
Effective disclosures under Form 5500 filings help plan fiduciaries deal with the brunt of the Department of Labor's persistent monitoring and penalties. But the quality of reporting depends entirely on whether benefit managers and plan fiduciaries select qualified auditors and service providers.
Speaking at the International Foundation of Employee Benefit Plans' 60th Annual Employee Benefits Conference, Ian Dingwall, chief accountant for the DOL's Employee Benefits Security Administration, said that Form 5500, a disclosure document for plan participants and beneficiaries, is the main focus of EBSA and its office of the chief accountant.
"I'm in the business of making sure all of you [employers and fiduciaries] are timely reporting on the Form 5500 all that is required to be reported on the form 5500," Dingwall said to IFEBP conference attendees in Boston this week. He added that plan fiduciaries can avoid the DOL penalties and fees by just hiring the right auditor.
"The idea is to avoid this whole process by hiring only good auditors," Dingwall explained, while noting that this doesn't necessarily mean that the firm with the cheapest fees is the best for the plan and plan participants. And audit quality can be a big problem, with 32% of audits being deficient in some way, according to DOL statistics.
The plan auditor universe includes over 7,300 certified accounting firms that perform over 82,500 plan audits. But DOL's chief accountant highlighted that 1% of plan auditors audit 100 or more plans; this equals roughly 42% of all plans, or 91 million participants. Approximately 50% of plan auditors audit only 6% of all plans, highlighting a tight grasp of the market from a select bunch of auditing consultant firms.
Avoid Audit Firms that "Dabble" in Employee Benefit Plans
Dingwall said that audit firms that tend to "dabble" among employer groups may not be the perfect fit for multiemployer plans, either. The DOL found that of the 238 deficient multiemployer plan audits, 81 had more than five deficiencies found in their audit recap.
"Some of these guys that are out there auditing employee benefit plans [are] what I call dabblers," explains Dingwall. "They audit one or two plans. They might not know a thing about multiemployer plans, and it's because it's a different world."
Meanwhile, employers should probably take a hard look at areas such as participant data, where 65% of audits were deficient, Dingwall noted. "Participant data is really important and we find that's one of the biggest problems we have," he said.
"If you hire an auditor that is not asking a lot of questions about participants, you've got a bad one," said Dingwall.
According to Ann Kellen, director of finance at Wilson-McShane Corporation, a third-party administrator, the DOL audit process starts primarily with complaints from participants and different service provider violations. Regional and national DOL initiatives also play a hand in enforcement activity, she said.
Gary A. Thayer, of law firm Archer, Byington, Glennon & Levine, agreed that service provider arrangements are becoming more and more of a headache for employers when the DOL begins its audit process. The former investigator for the DOL and EBSA, who now counsels multiemployer benefit plans, told conference attendees that a potential service provider investigation can lead to a full-blown fiduciary audit over time.
"It could take whatever investigation they have on a service provider and they can assess whether or not there is a violation by way of what that service provider may be doing by way of contract or conduct," Thayer said. The DOL can also widen "the investigation to fiduciaries," he added.
US Adults Have
14 Million Major Medical Conditions Attributable to Smoking
The 14 million figure is generally conservative owing to the existence of other diseases and medical events that were not included in these estimates. Cigarette smoking remains a leading cause of preventable disease in the United States, underscoring the need for continuing and vigorous smoking-prevention efforts.
Cigarette smoking has been found to harm nearly every bodily organ and is a leading cause of preventable disease, but current estimates of smoking-attributable morbidity by condition for the United States are generally unavailable.
Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 10/8/2014)
Editor's Note: The following is a recurring article. This Newsletter is often asked by readers for a list of medical stop-loss providers and their respective premiums. Below the first of a recurring article that attempts to lists stop-loss providers and annual premiums. Sources includes press releases, AM Best reports, conference presentations and more.
Other stop-loss leaders include the following list. However, we await reader response providing stop-loss premium volume (and additional carriers) so that each could be added to the table above.
Stop-loss Premium Volume is not the Whole Story
Industry executives question the purpose of a chart reporting only stop-loss premium without additional information such as:
Reader response and correction is encouraged. Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com.
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