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Third Quarter 2015 • Volume 22 • Number 3

Overseas work

By Debra Schneider, Esq., and Aleida Ortega Conners, Esq.

Labor audits By Ellen Nipp, QKA

Temporary staffing

By Eric J. Conn, Esq., and Lindsay A. Smith, Esq.

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Third Quarter 2015 Volume 22 • No. 3

4 7 8



People Interview


Matt Brandt Multicare Associates



Overseas work By Debra Schneider, Esq., and Aleida Ortega Conners, Esq.


Employment Law




minnesota Health care Roundtable


Department of Labor audits By Ellen Nipp, QKA

Temporary staffing By Eric J. Conn, Esq., and Lindsay A. Smith, Esq.

The new face of health care


Simplify benefit administration By Andrew Staab, JD

Behavioral Health Integration New pathways to care

Thursday, November 12, 2015 • 1:00-4:00 PM Downtown Minneapolis Hilton and Towers Background and Focus: Increasing evidence supports the link between access to mental health care and reducing health care costs. Primary care physicians often lack the expertise to diagnose behavioral health correctly and are not always able to easily refer a patient to a mental health care provider. Many initiatives nationwide are addressing this issue. It is so important that the ACA stipulated the development of the Behavioral Health Home in 2015. Some states, including Minnesota, are also creating Behavioral Health Home programs. Objectives: We will review numerous initiatives that support the development of new pathways to behavioral health care. We will introduce new ideas and discuss how to incorporate them into our health-care delivery system. We will examine the value they can bring and the challenges they will face. Our panel of industry experts will outline the steps that must be taken to increase the overall access to mental health care and the broad improvement in population health that this increased access will bring. Panelists include: • Sarah Anderson, MSW, LICSW, CEO, Psych Recovery, Inc. • Lee Beecher, MD, President, Minnesota Physician-Patient Alliance • Timothy P. Gibbs, MD, FAPA, DFAACAP, Chief Medical Officer, Natalis Counseling and Psychology Solutions • Martha Lantz, MSW, LICSW, MBA, Executive Dir., Touchstone Mental Health • Judge Kerry W. Meyer, Hennepin County Criminal Mental Health Court • Jane Pederson, MD, Medical Affairs Director, Stratis Health • Jeff Schiff, MD, MBA, Medical Director, MN Dept. of Human Services • L. Read Sulik, MD, Chief Integration Officer, PrairieCare Sponsors include: • MN Community Healthcare Network • MN Dept. of Human Services • Natalis Outcomes • PrairieCare • Psych Recovery, Inc. • Stratis Health Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable.

Publisher Mike Starnes | Editor Lisa McGowan | Associate Editor Richard Ericson |

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Employee Benefits Planner is published quarterly by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email All views and opinions expressed by authors of published articles are solely those of the authors and do not represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (four copies) are $24.00. Individual copies are $5.00. Reprints of individual articles are available upon request.

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Large Increases Proposed for Individual Health Plans Several Minnesota insurers have proposed significant rate increases for individual health insurance plans, according to the Minnesota Department of Commerce. Federal law requires any proposed premium increases above 10 percent to be disclosed months in advance for review and approval. Twenty-seven plans have proposed increases above 10 percent, with an average proposed increase of 43 percent. The highest proposed increase was 74 percent, for a plan offered by Time Insurance Co. Blue Cross Blue Shield of Minnesota has proposed increases of more than 50 percent for nine of its individual health plan products. About 171,000 of the 300,000 Minnesotans enrolled


in individual plans would be affected by these increases alone. Rates must be approved by the Minnesota Department of Commerce before they are official, and the department can deny or modify rates it finds excessive. It accepted public comments on the proposed increases through July 31. Official rates will be announced Oct. 1 and they will take effect Jan. 1, 2016. Gov. Mark Dayton called the hefty proposed increases “outrageous” and called for a “rigorous review” of the proposals, which Minnesota Commerce Commissioner Mike Rothman has committed to doing.

Minnesota Drops 3,900 Jobs in July Employers eliminated 3,900 jobs in July, according to seasonally adjusted numbers released by the Minnesota Department of

Employee Benefits Planner Third Quarter 2015

Employment and Economic Development (DEED). However, revised numbers for June showed an additional 2,700 jobs gained, bringing the total June gains to 5,600 jobs. The sectors that had the most job losses were leisure and hospitality, down 3,700; construction, down 2,000; trade, transportation, and utilities, down 1,700; education and health services, down 1,200; manufacturing, down 300; and other services, down 100. However, some sectors showed job gains, including government, with 2,700 new jobs; professional and business services, with 1,400 new jobs; financial activities, with 500 new jobs; logging and mining, with 300 new jobs; and information, with 200 new jobs. Minnesota has gained 43,719 jobs over the past year, showing a growth rate of 1.5

percent. The highest gain is in education and health services, which gained 14,356 jobs in the past year. In addition, professional and business services jobs are up 10,100 since July of last year; leisure and hospitality jobs are up 8,381; trade, transportation, and utilities jobs are up 7,232; manufacturing jobs are up 3,074; financial activities jobs are up 2,240; and construction jobs are up 724. The greatest losses in the past year are in other services, down 1,056; logging and mining, down 893; and information, down 490. The Minneapolis-St. Paul metropolitan statistical area (MSA) shows the most jobs gains in the last year, up 2.1 percent. Jobs in Duluth-Superior MSA jobs are up 1.3 percent; jobs in Mankato MSA are up 1 percent; jobs in St. Cloud MSA are up .4 percent; and jobs in Rochester MSA are up .1 percent.

Dayton Names Members to Health Care Task Force Gov. Mark Dayton has announced his appointments to the 11-member state task force that will evaluate the future of health care programs in Minnesota, including MNsure and MinnesotaCare. The Task Force on Health Care Financing will look at MNsure’s longterm financial viability, the possibility of moving to the federal health care exchange, and changes to other public health care programs, according to a letter written by Dayton in March, when he proposed $500,000 to fund the task force and analysis of state health care programs. “The launch of MNsure created serious problems for many consumers. Although we have seen significant improvements, there are still important unresolved issues,” Dayton wrote. “Looking ahead, we must make some major policy and programmatic decisions that will strengthen Minnesota’s position as the nation’s health care leader, while making the best use of our state’s financial resources.” The 33-member task force began meeting in August and will report its final recommendations to Dayton and the Legislature by Jan. 15, 2016.

Obesity Rates in Minnesota Remain Lower than Neighboring States Obesity rates in Minnesota have stayed steady, unlike other states in the region, according to a recent report from the Minnesota Department of Health (MDH). MDH analyzed data from the Centers for Disease Control and Prevention’s (CDC)

Behavioral Risk Factor Surveillance System, which surveys 400,000 Minnesotans annually. They found that obesity rates in Minnesota dropped below 26 percent in 2010 and have stayed below that rate since. It was the only state in the region to bring the rate below this threshold. Meanwhile, other states in the region, which includes Iowa, North Dakota, South Dakota, and Wisconsin, saw obesity rates increase to between 29 percent and 31 percent in 2013, the most recent CDC data available. The report also shows that the number of Minnesotans that were at a healthy weight in 2013 increased by more than 60,000 since 2010. According to MDH, this is more than 11 percent higher than the U.S. overall. The reduction in obesity rates leads to significant cost savings as well. MDH estimates that the state saved $265 million in obesity-related medical expenses as of 2013. In addition, about 18,600 Minnesotans covered by state health care plans moved to a healthy weight in 2013, which MDH estimates saves up to $9 million for taxpayers each year.

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Ed Ehlinger, MD, Minnesota commissioner of health, reports that Minnesota’s progress on obesity rates is related to the Statewide Health Improvement Program, enacted in 2008 in response to increasing health care costs due to obesity. “Obesity is a complex condition with many contributing factors,” said Ehlinger. “We know diet and exercise are key, and I am confident that Minnesota’s success is closely tied to investments by the Statewide Health Improvement Program and its community and private sector partners to increase Minnesotans’ opportunities for healthy eating and physical activity.” News to page 6

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News from page 5

Assurant Health Exits Health Insurance Market Assurant, Inc., the parent company of Milwaukee-based Assurant Health, has announced that it will exit the health insurance market. About 8,000 Minnesotans are covered under individual policies through Assurant Health under the names John Alden Life Insurance Co. and Time Insurance Co., and 66 Minnesotans are covered by Assurant Health in group plans through employers. The company will not offer plans for 2016 open enrollment. “Our decision to exit the health insurance market enables us to sharpen our focus on the housing and lifestyle markets, where we see the greatest

opportunity for profitable growth,” said Alan Colberg, president and CEO of Assurant, Inc. “After a thorough review of alternatives for our health business, we believe the actions announced today allow us to uphold our commitments to policyholders while freeing up resources in 2016 to support our capital management strategy. We remain strongly committed to ensuring a smooth and orderly transition for our customers, agents, and employees.” Assurant Inc. plans to completely exit the health insurance market by the end of 2016. While none of the policies currently in place will be affected, the company started sending letters out to its policyholders beginning June 15, when it planned to begin ceasing sales of its individual medical, small group, and short-term medical

health insurance policies. Assurant will cut about 1,700 jobs and estimates that total costs from this move will be between $175 million and $250 million. The company lost about $148 million on individual policies over the last 15 months due to medical claim costs that were higher than expected. Earlier this year, it proposed significant premium increases to the federal government for its plans in 2016.

Pharmacy Benefit Spending Rising Net prescription drug costs increased 13 percent in 2014, according to the 2014 Report on Prescription Drug Costs from Prime Therapeutics. Traditional drugs showed a 4.2 percent increase, but specialty drugs accounted for the

majority of the overall cost rise with an increase of 25.8 percent. According to the report, this was due to changing dynamics in the industry, including drug price increases; new, high-cost specialty drugs; less opportunity to switch to generic drugs; increased use of drugs; and the addition of 1.4 million health insurance marketplace members with greater health needs. Drug price increases were responsible for two-thirds of the increase in net prescription costs. And three therapeutics categories were responsible for more than 50 percent of all new drug spending in 2014—hepatitis C, diabetes, and anti-inflammatory drugs. Prime Therapeutics predicts that costs will continue to rise rapidly over the next few years.

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Employee Benefits Planner Third Quarter 2015

People Stacey Busta has been promoted to director of human resources at full-service real estate company Premier Management, St. Paul. She joined the company as human resources manager in 2012. Osmo Vänskä /// Music Director

Andrew Daly, CPA, JD, has joined the Minneapolis office of Gray Plant Mooty as special counStacey Busta sel in the firm’s Employee Benefits and Executive Compensation Practice Group. Mary Fleming has been promoted to vice president of human Andrew Daly resources at Canterbury Park, Shakopee. Fleming joined the company in 1994 and will lead all aspects of human resources. John C. Hauge, MA, JD, has joined Felhaber Larson, MinneapMary Fleming olis. Previously in private practice, he is a Minnesota State Bar Association Certified Labor and Employment Law Specialist. Joy Linsday, SPHR, has been hired as vice president, human John C. Hauge, MA, JD resources, at Liberty Diversified International (LDI), headquartered in Minneapolis. Linsday becomes a member of the LDI executive management team and will oversee human resource functions for all LDI businesses. She will superJoy Linsday, vise talent acquisition and development, benefits, SPHR compensation, and employee communications as part of her duties. Previously, Linsday served Carlson Companies as vice president of human resources for its Global Hotels business unit. Linsday holds a Senior Professional of Human Resource (SPHR) designation from the HR Certification Institute, an internationally recognized, independent certifying body. Kevin McKinnon is the new deputy commissioner of economic development at DEED, replacing Robin Sternberg, who is moving out of state. McKinnon joined DEED’s Business and Community Development division as director of business development in 2006 and was named executive director of the division in 2012.

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In his new position he oversees DEED’s Business and Community Development programs, as well as the Minnesota Trade Office and the Office of Broadband Development. Business and Community Development is responsible for more than 24 programs at DEED, focusing on such areas as business development and finance, small business assistance, community development, and job training. Kathy Rasmussen is the new human resources director for Dominium, a Plymouth-based owner, developer, and manager of apartment communities nationwide. Her background includes more than 15 years of experience leading human resources at companies with 150 to 5,000 employees. Kathy Rasmussen

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Third Quarter 2015 Employee Benefits Planner



PrimaCare Direct: A health care cooperative P  lease tell us about PrimaCare Direct. Technically, PrimaCare Direct is a health care cooperative made up of health care providers who work together to market medical services directly to patients and employers. I prefer to think of PrimaCare Direct as a group of physician practices that understands how to make positive changes in health care by thinking outside of the current system. Today’s system is dominated by integrated delivery systems that are primarily governed by hospitals. Primary and specialty providers who are employed by hospitals are often “obligated” to refer patients to the hospital. The goal should really be for health care providers to keep patients healthy and out of the hospital. Providers should be free to make decisions with their patients without any outside influence. Cooperative practices that work directly with health care purchasers (patients, employers, and government agencies) can be creative in how they finance and deliver health care. PrimaCare Direct’s care delivery model is based on a model called direct primary care (DPC) or direct pay medical home. The defining elements of DPC is to create improved access to primary care and to ensure that patients have an enduring and trusting relationship with their primary care providers. Fee-for-service incentives are replaced with a simple flat monthly fee. This empowers the doctor/patient relationship and is how we achieve superior health outcomes, a better patient experience, and lower costs. PrimaCare Direct has also started to include specialty services. Specialty practices can join the cooperative and provide procedures or care packages for one bundled fee instead of having multiple charges from facilities, physicians, and ancillary care providers. Often, specialty physician groups can deliver the same high-quality services in an outpatient setting for 20 percent to 50 percent less than at a hospital.

W  ould you explain consumer costs and how you figured them? The flat monthly fee for a patient to enroll in PrimaCare Direct is $75 a month. The monthly fee is capped at four family members, so additional family members are free. To come up with the $75 fee we analyzed Multicare Associates claims data and examined


Employee Benefits Planner Third Quarter 2015

H  ow does your approach to providing access to health care translate into lower overall cost of care?

Matt Brandt Multicare Associates Mr. Brandt is CEO of Multicare Associates in the Twin Cities, a primary care physician group that has been piloting a direct pay primary care model since 2008. In 2013, he founded a health care cooperative, PrimaCare Direct, which includes over 200 doctors and offers direct pay health care services to employers and patients in the Twin Cities. Mr. Brandt is also CEO of PrimaCare Direct and a board member for the Minnesota Healthcare Network. In 2013, he received the Emerging Leader in Healthcare Award from Minnesota Business.

what an active patient (defined as a patient who had at least two visits in the past 18 months) spent annually on services at Multicare by age, gender, and insurance class. We also compared data from different health plans to determine what their per member, per month spend was on primary care. Then we looked at our primary care spending and researched what other direct primary care practices were charging. The end result was $75 per member per month. The good news is that this price point is working well, patients and employers seem to find it reasonable, and clinics are happy with the reimbursement. We have only a few instances where the costs to care for a specific patient significantly exceeded the monthly fee.

When discussing cost of care, we often look at chronic disease as being one of the key drivers to cost. Currently, the big trend for employers is to offer a high deductible health plan, but the problem with this is that it discourages patients from visiting their doctor, especially those suffering from chronic diseases such as asthma and diabetes. Instead of managing their care with their primary care provider they wind up in the emergency room, which drives up the cost of care. One ER visit can pay for eight primary care visits. PrimaCare Direct eliminates the barrier for patients to see their primary care doctor. It encourages good utilization (teaching a patient to use their inhaler properly) versus bad utilization (a patient ending up in the ER with an asthma attack). Independent physician groups have typically been very good at developing outpatient capabilities, imaging centers, surgery centers, diagnostic labs, etc., and these services cost less than hospital-based services.

W  hat kind of results have you had with PrimaCare Direct so far? Early results have been promising. Multicare Associates has been using this model with its employees for some time and has kept its health plan costs under control for the past seven years. Over that time, the average cost has declined slightly, which is incredible considering that the industry average has increased in cost somewhere between 8 percent to 10 percent a year depending on which source you quote. The current PrimaCare membership is showing a dramatic decrease in ER visits with the rate being 112 visits per 1,000 patients versus the norm of 298 visits per 1,000. Groups running the DPC model of care around the country are seeing similar results.

W  hat have been the biggest challenges? The two biggest and unexpected challenges have been, 1) the number of patients on government programs or receiving benefits from a government entity, and 2) dealing with insurance brokers. When we first started marketing PrimaCare Direct to our patient base it was

shocking to realize how many patients were receiving insurance through a government agency. We knew how many patients were on Medicare or Medicaid but we didn’t realize the number of government employees who received benefits such as postal workers, state workers, MnDOT workers, county workers, etc. This is a barrier for PrimaCare because it is rare for government employees to have a high deductible or any deductible at all unlike private sector employees where a $5,000 deductible is the norm. This just means that the PrimaCare model does not currently apply to these workers, but that may change over time. The other barrier is dealing with insurance brokers who are generally paid in commission from the insurance company they work for. This sets up a weird incentive where their commission increases when a premium goes up, yet, they claim to be working on an employer’s behalf. A lot of these brokers don’t really have a solid grasp of how health insurance works and even less knowledge about how health care is delivered. So trying to find brokers to work with who understand the PrimaCare Direct model and are not afraid to make changes has been difficult.

H  ow can physicians become involved?

H  ow can employers become involved?

PrimaCare Direct is open to both primary and specialty practices in Minnesota and western Wisconsin. We are looking for physicians who want to help us continue to develop our business model of keeping the focus on patient-centered care, where the patient is the client and a true physician/​patient relationship is the key to success.

If an employer is searching for a way to lower their health care costs without sacrificing access, coverage, or quality then PrimaCare Direct is a potential solution. Our care model, coupled with our third-party administrator and stop-loss partners, can customize a solution for a company’s employees.

 In an ideal world, what does the future hold for PrimaCare Direct?

The goal should really be for health care providers to keep patients healthy. P  rimaCare Direct does not cover major medical events. How do you advise patients to obtain this coverage? We advise patients to obtain a high deductible health plan to insure against catastrophic events (such as cancer or traumatic injury). PrimaCare Direct is currently working to develop and sell its own high deductible health plan that pairs with our direct primary care plan.

Ideally, I would love to see PrimaCare Direct grow to cover over 10,000 people here in the Twin Cities within the next year. At that scale it would be hard to refute our results and it would be easier to more aggressively market the concept. This is a stretch goal, but I think it is very doable at our current pace as we have more than 200 doctors currently on board who care for over 300,000 patients. If we can convert over 3 percent of those to the new model we can achieve this goal. From there, I would like to see us grow the model to include a large enough portion of any doctor’s panel that they can change the way they deliver care for all patients, not just those enrolled in our program.

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Third Quarter 2015 Employee Benefits Planner


S ta f f i n g

Overseas work T

he world becomes smaller as we receive news, products, and ideas from around the globe. This increasing reliance on conducting business in multiple markets results in the need to visit, work, and, sometimes, relocate employees abroad. Because international travel and work visas are awash in laws, regulations, and ever-changing policies, be sure that the proper visas, immigration forms, insurance, health care, and customs requirements are taken care of before sending employees overseas.

What employers need to know By Debra Schneider, Esq., and Aleida Ortega Conners, Esq.

The assignment In assessing what is needed for your foreign-bound employee, understand the nature of the assignment: • How long will the employee be abroad? • What is the purpose of the visit? • Which entity will be responsible for salary and benefits? • Will the employee be visiting clients or an affiliate office, or will she or he be stationed abroad?

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Employee Benefits Planner Third Quarter 2015

Every country’s immigration laws are different, so it is critical to investigate the specific country’s immigration requirements. Some countries require foreign workers to apply for a work permit before entering the country. Others have broad definitions of business visas and don’t require a formal application.

country. Canada, for example, is extremely strict on DWI convictions, and even convictions for reckless driving if alcohol may have been involved. Obtaining waivers of inadmissibility for employees can be time-consuming and costly. Screen candidates before overseas travel regarding prior criminal arrests, convictions, and possible prior immigration violations.

Most initial overseas travel involves a request for a business visa. American citizens are often exempt from many countries’ formal business visa applications when entering a country to attend meetings, negotiate contracts, or visit foreign offices. (Such exemptions often have a 90-day limit.) Limits of the business visa become clear when an employee needs to conduct gainful employment, provide direction and support to an overseas office, or engage in activities that would otherwise be provided by local staff. Understanding the nature of the assignment will better equip you to avoid pitfalls such as violations, monetary penalties, or even detention of your employees.

Begin any supporting work for a global transfer as early as possible.

Obtaining work permits Each country has specific requirements for obtaining work permits. Most are tied to the credentials and experience of the employee and why he or she is needed in the country to work. Barriers to work permits exist in nearly every country to protect the local workforce. Therefore, best practice is to review the employee’s resume, job description, and education to determine if a work permit is feasible. You might, for example, determine whether your employee has skills and training that cannot be found among the local workforce. Describe job duties Describing job duties with enough specificity to meet the legal requirements for a work permit is essential for proper visa preparation. The purpose of a visit or assignment may be clear to a high-level manager, but an employee herself may not understand her role abroad in the big picture. Ensure all levels of staff involved in an overseas transfer are familiar with the laws and potential restrictions on work allowed to be performed abroad. The scope of the assignment should be spelled out in the visa paperwork or work permit, and thoroughly understood by the employee. Understand business structure Many countries have specific work permits for employees transferring from one affiliate/subsidiary office to another. Therefore, understanding the corporate relationship helps determine what types of work permits may be available. Joint ventures or unregistered business entities may not qualify to sponsor a work permit. In addition, some countries have baseline experience requirements with the related entity before a transfer can occur. Other countries may allow highly skilled workers to self-petition for a permit without being formally associated with a business entity. For example, if a U.S.-based company creates a new foreign office, the type of entity created and whether it is structured to support foreign workers is an important consideration if staffing will be done from the U.S. Know your employee’s background Crimes that would not prevent someone from being hired in the U.S. could easily prevent issuance of a work permit or visa in another

Household goods Employees moving abroad for a long-term assignment will want to take personal belongings. However, many countries won’t clear household goods until a work permit is issued. Logistics and timing of travel for employees and their belongings should be determined in advance, so that employees have items needed for their new home as soon as they arrive.


Family Employers should determine whether family members will accompany an employee. There will be additional costs to obtain visas for family members, and not every country or work assignment allows spousal work permits. Moreover, the age that defines a dependent child can differ from country to country. Same-sex marriages are not recognized in most countries, limiting the ability of same-sex spouses to accompany their loved one. Thus, it is useful to provide a relocation overview that includes school options for children, health Overseas work to page 30

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E m p l oy m e n t L aw

How to respond By Ellen Nipp, QKA


s a plan sponsor, at some point you may receive a letter from the Department of Labor (DOL) notifying you that your qualified plan will be audited. The DOL is responsible for the administration and enforcement of the Employee Retirement Income Security Act of 1974 (ERISA).

Reasons for audits There are four main reasons a plan comes to the attention of the DOL and results in an audit: • Errors on Form 5500 • Late deposits and deferrals • A participant complaint


Employee Benefits Planner Third Quarter 2015

• Chance (Each year, the DOL selects issues it wants to examine more closely.)

The information request When the DOL notifies you that your plan will be audited, it includes a list of information for you to prepare and submit to it for review. This can be a long list and can cover information going back three or four years. In addition to all plan documents, you likely will be asked for all payroll records, enrollment forms, participant disclosures, and participant statements. Generally, the DOL will give you 30 days to submit the requested information. Once you have submitted the requested data, the DOL will give you a date and time for an interview, which may be by phone or in person.

funds, which may result in a civil action. Deficiencies also may result in fines and may lead to more frequent audits. Case study Now that we’ve covered the basics of a DOL audit, let’s see how they might play out in a real-life situation. In 2012, a plan sponsor received a letter from the DOL announcing an audit. The initial DOL letter did not specify a reason for the audit. While the DOL reviewed all aspects of the plan, it eventually focused on late deposits.

If the DOL is on-site, any employee conversation is on the record.

The interview On the day of the interview, invite everyone who is involved with the plan to attend. Some plans will invite a third-party administrator (TPA) or an ERISA attorney. (A TPA provides administrative services such as 5500 preparation, compliance review, and plan reports for the retirement plans it serves.)

When the plan sponsor client received the DOL letter, it immediately contacted its TPA for assistance in gathering data to fulfill the request. As usual, the DOL wanted three years of complete plan information to be delivered within 30 days. Although it eventually took more than three months to accumulate all the requested information, the DOL was willing to work with the plan sponsor because the latter responded immediately, communicated regularly with the DOL, and regularly discussed its time constraints with the DOL.

Managing the interview requires trying to give a direct answer to each question the DOL agent asks, and only that question. By offering additional information, you could inadvertently widen the scope of the audit.

In retrospect, a number of things could have triggered the audit. The sponsor had a late deposit in each of the last three years, although it reported the late deposit and self-corrected each time it happened. The plan sponsor also had a nontraditional asset in the

Preparing for the interview and audit

Whenever the agent asks a question, the person who is responsible should answer. Encourage everyone to answer truthfully. If you have made a compliance or operational mistake with your plan, this is the time to let the DOL know. It is better to come clean right away, especially if you have already fixed the problem and can show how you remedied it and have put steps in place to prevent future mistakes. The audit After all the information is compiled and the initial interview occurs, the agent may schedule a time to visit. While this sometimes happens at the DOL office, more often the DOL comes to your facility. If the DOL is on-site, any employee conversation is on the record. The agent can pick up information just by listening to conversations taking place around him or her. Follow-up Once the agent finishes the audit, he or she will discuss it with a supervisor. The agent then may have additional questions. Then, the DOL will make you aware of any deficiencies discovered and discuss remedies with you. The closing letter The DOL will write a closing letter summarizing what it found during its audit, any operational deficiencies in your plan, and what you did to fix them. It won’t issue the closing letter until you remedy all the deficiencies. This means the final issuance of the closing letter can take as much as six months to a year after you start the process. Consequences While most audits are routine and result in only a closing letter identifying minor deficiencies, some audits can uncover more serious issues. These issues often revolve around inappropriate use of plan

Department of Labor audits to page 29

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Third Quarter 2015 Employee Benefits Planner



Temporary Staffing OSHA’s enforcement hammer By Eric J. Conn, Esq., and Lindsay A. Smith, Esq.


n April 2013, the Occupational Safety and Health Administration (OSHA) declared that protecting temporary workers would be among its highest priorities. That has proven true under OSHA’s Temporary Worker Initiative, designed to strengthen protections for such employees.

dispute that, but the question remains: Who is responsible under the law when a temporary worker is exposed to hazards—the staffing agency or the host employer?

OSHA maintains that temporary employees are entitled to the same safety and health rights as other workers. No one would

Although OSHA has regulated safety of temporary workers for many years, its new focus has been sparked by several concerns. These include the growth of the nation’s temporary workforce, the nature of work performed by temporary workers, and anecdotal reports of recent fatalities.

Issues prompting the Initiative

Affordable Care Act. The treatment of temporary workers is expected to gain greater significance under the Affordable Care Act (“ACA”). The ACA requires employers with 50 or more workers to provide affordable health insurance coverage to employees working at least 30 hours per week. This will lead employers to increase temporary worker arrangements to remain below 50 employees and to reduce the number of workers with 30-hour weeks. When Massachusetts implemented its version of the ACA, temporary employment in Massachusetts grew six times faster than in the rest of the country. The nature of temporary work. OSHA reports that temporary workers are at increased risk of workplace injury because workers begin new jobs several times a year. OSHA believes that employers are less willing to devote resources to training temporary workers because they may only be on-site a few days or weeks. OSHA also thinks that employers use temporary workers for unpleasant or dangerous jobs to shield full-time employees from those tasks. Finally, the agency is concerned that temporary workers are more vulnerable to safety-related retaliation because their employment is more tenuous. Recent fatalities on first days on the job. OSHA’s director has discussed a surge in temporary worker fatalities over the past several years, many occurring during workers’ first days on the job. He suggested this trend results from host employers inadequately training temporary workers regarding potential workplace hazards and measures workers can take to protect themselves. 14

Employee Benefits Planner Third Quarter 2015

Temporary Worker Initiative Given these factors, OSHA launched a Temporary Worker Initiative to ensure that staffing agencies and host employers understand their respective safety responsibilities. Although there exist numerous types of part-time and contract employment relationships, for purposes of the Initiative, OSHA defines “temporary worker” to include only someone who works under a host employer/staffing agency employment structure. OSHA’s goals for the Temporary Worker Initiative are to: 1. Protect temporary workers from workplace hazards; 2. Ensure staffing agencies and hosts understand their safety obligations; and

In this context, OSHA suggests that the staffing agency, which maintains a continuing relationship with its employees, must at least inform employees of the general elements of the Hazard Communication Standard and ensure the host provides adequate site-specific training. The host, according to OSHA, bears the primary responsibility for this training because the host is better positioned to inform workers of chemical hazards present at their worksites.

OSHA defines “temporary worker” to include only someone who works under a host employer/staffing agency employment structure.

3. L earn about hazards in workplaces that use temporary workers. To achieve these goals, OSHA is producing compliance assistance materials such as fact sheets and webpages; conducting outreach to stakeholders; and exercising enforcement. Specifically, OSHA instructed its compliance safety and health officers to look for the presence of temporary workers during every inspection, regardless of the initial purpose of the inspection, and to issue citations where temporary workers were exposed to violative conditions or were not given adequate training. OSHA also has issued letters of interpretation and other guidance documents that clarify whether staffing agencies or hosts are responsible for certain safety requirements. Topics addressed have focused on training, chemical hazard communication, and keeping records of injury and illness. In each of these areas, OSHA’s enforcement philosophy begins with the premise that both the staffing agency and host employer are responsible in varying degrees. Determining which entity is accountable—and therefore which entity can be cited for a violation—generally depends on which one controls the means and methods of the work.

Injury/illness recordkeeping/ reporting

Responsibility to record injuries is based upon which employer supervises the temporary worker’s daily tasks. The OSHA regulation on recordkeeping addresses this issue expressly. For recordkeeping purposes, day-to-day supervision occurs when, “in addition to specifying the output, product or result to be accomplished by the person’s work, the employer supervises the details, means, methods and processes by which the work is to be accomplished.” When the host employer has full supervisory control over employees, the host employer is responsible for recording and reporting injuries and illnesses of temp workers. When only the temporary staffing agency exercises dayto-day supervision over employees, the temporary staffing agency Temporary workers to page 28

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Training There are specific OSHA standards that include training requirements across various industries, types of worksites, and job duties. Where these requirements apply to temporary workers, it is generally the staffing agency’s responsibility to provide basic training before sending the workers to a host’s facility. In most cases, however, OSHA assumes that the host employer is better positioned to provide workplace-specific training, so that duty typically falls to host employers. Hazard communication Chemical-related hazard communication training illustrates a prime example of the shared responsibility OSHA promotes. Per OSHA’s guidance, both the staffing agency and the host employer must ensure temporary employees are effectively informed of exposures to hazardous chemicals. This is due to the fact that the staffing agency actually employs the temporary worker, while the host employer creates and controls the chemical hazards workers may encounter. Third Quarter 2015 Employee Benefits Planner


Minnesota health care roundtable

Mr. Starnes: Today we will talk about expanding medical professional relationships, which can take many forms. In some—an oncologist working with a radiologist, for example—there is a well-defined protocol for communication and continuity of patient care. We want to focus more on medical doctors working with medical professionals who are not MDs. Let’s start with a definition. What is a medical professional?

Dr. Hu: It has to do with a degree of specific medical training in some specific field as well as professional interest. It has to involve some aspect of medicine, however broadly you want to define that.

About the Roundtable Minnesota Physician Publishing’s forty-third Minnesota Health Care Roundtable examined the topic of The New Face of Health Care: Expanding medical professional relationships. Seven panelists and our moderator met on April 23, 2015 to discuss this topic. The next roundtable, on Nov. 12, 2015, will address Behavioral health integration: New pathways to care

Dr. Sawyer: In our institution, we not only train chiropractic doctors but acupuncturists and massage therapists, and our definition of massage therapy is therapeutic massage. We very much consider them to be medical professionals. Dr. Desai: When you define a medical professional, you get into a lot of political discussions, and some people get their hackles up. Folks who have gone through medical school or dental school or chiropractic school sometimes show an ingrained defensiveness based on the school they’ve attended and the education they’ve had. I’m part of a multidisciplinary practice, so I work very closely with behavioral health specialists, psychologists, licensed social workers, physical therapists, and others. Oftentimes I work with chiropractors or other medical professionals, as well as with acupuncturists. The value of that is undeniable. Mr. Hustvet: I like the term “health care professional.” Our current discipline is really pushing to alleviate some of the problems of having a limited number of physicians. Would I take it personally if I were called a “mid-level provider?” I would really look more at what I’m able to do for the patient. Am I able to meet a need in a timely fashion? Am I able to assist and provide care where maybe there would have been a delay? Mr. Starnes: As science and training expands, many health care professionals have the ability to make frontline diagnoses of conditions that could be shared with physicians. Any examples of the ways in which these individuals could work with physicians? Dr. Gulon: Dental schools now include the team-based approach to care as part of the


Employee Benefits Planner Third Quarter 2015

payment. When a patient walks in our door we manage that patient in a silo, and we aren’t thinking of other providers that might be able to have a better impact or an additional impact on that patient. Mr. Wingrove: A lot of us are still getting to know each other, and I think that is one of the keys to having successful interdisciplinary approaches. We’re being forced now to look outside of our own box and collaborate with other people. In the long run, I think that’s going to serve the patients well. It’s probably something we should have done a decade ago. Dr. Desai: Patient ownership is an area that we tend to ignore. It’s the most uncomfortable of the areas to discuss. The cultural issues surrounding patient ownership are the ones that are the hardest conversations to have.

The new face of health care Expanding medical professional relationships curriculum. Dentists are trained to not only work on prevention, but disease treatment as well—and, like our physician colleagues, to deliver care over the lifetime of our patients. It’s obvious that everything that goes into the mouth pretty much enters all the pathways of all the basic systems of the body. Understanding that and applying disciplines and approaches to care that impact and/or prevent it are going to be useful in at least the teamwork process in health care. Mr. Starnes: Let’s talk about expanding the relationships between health care professionals and the benefits this can bring. What are some of the existing barriers to this more collaborative approach? Dr. Sawyer: The biggest barriers really have to do with payment and the incentives in

Dr. Gulon: I see this as an opportunity, not as a barrier. First of all, 40 percent of the population seeks dental care in any given year. Fifteen percent of those people don’t see a physician, and that’s a problem. If we’re presented with conditions in which we could be a source of referral to the physicians through appropriate screening, whether it’s hypertension, which we do routinely, oral cancer screening examinations, diabetes screening, or sleep apnea screening, there are windows and/or opportunities to collaborate at a higher level with our physician colleagues. Mr. Starnes: Are we are going to foster better relations between provider types if the consumers themselves broaden their approach to health? Mr. Hustvet: Changing a patient’s view on taking ownership of their health isn’t going to happen in a five-minute conversation at a physician’s office. It probably won’t happen even after three or four five-minute conversations at the physician’s office. Dr. Hu: Say you need to get a CT scan and an MRI. Each costs different amounts at different places, whether it’s inpatient, outpatient, or in hospitals. There’s very little transparency, so even if they want to be involved in making those decisions in a cost-effective manner based on their insurance or deductible, they can’t do it.

Minnesota health care roundtable Mr. Johnson: We all need to provide education to our patients about preventive care and following up with preventive checkups, because it can’t be a burden for just one profession. Dr. Hu: I’m a specialist, a vascular surgeon, so my view may be skewed towards specialty care. Again, we’ve been siloed for a long time. We have radiologists who do angiograms and surgeons who do surgery, but those barriers have changed, and everyone wants to protect their turf. I think the financial barriers are the first hurdle and probably the biggest hurdle in order to build a multidisciplinary team with a common goal. Mr. Starnes: We need to better understand the levels of training of different kinds of providers. How early in one’s health care career should this learning begin? Mr. Johnson: In the physical therapy program it happens early, and for good reason. Everybody is in learner mode. I think it needs to be a little bit more robust, actually, so training would continue beyond those initial few years. Mr. Starnes: What about health care professionals who are well into their careers and well removed from the academic or school environment? Mr. Hustvet: Sometimes it’s directed by a physician above everyone who pulls teams together to promote exposure and greater comfort levels with the different fields. Being outside the facility, it’s really a challenge for us. We spend a lot of effort trying to track

“You want to do the best thing for the patient.” Michael Hu, MD

people down and explain what kinds of services and offerings we have, asking questions about their needs, and where we can fill in the gaps. Mr. Wingrove: I represent the profession that will literally decide for about 80 percent of you in the room today at least once whether you live or die. That’s about 10 percent of what we do. We have another 30 percent that deals with your urgent care needs, and about 60 percent that involves your social needs. Until recently, we weren’t training our professionals in how to deal with your social issues beyond some of the safety issues. That’s one of the real promises of the new generation of community paramedics. It’s taking a professional that is super-sharp in lifesaving skills and retraining them to do the majority of the work they actually perform each day, which involves more psychosocial skills. Mr. Starnes: How can reimbursement mechanisms further collaboration? Dr. Desai: There’ll be a shortage of 90,000 physicians within the next two to five years, and certain states are suffering from it more acutely than others. If we formed a care team with seven health care professionals and we all saw the patient together, only one of us could get reimbursed. We need to create incentives for people to want to be part of that team. If you come to see me as a patient, I will almost always refer you to a physical therapist, possibly a behavioral health specialist, an acupuncturist, or a surgeon.

Mehul Desai, MD, MPH, practices at the Maple Grove and Fridley offices of Medical Advanced Pain Specialists (MAPS). Board-certified in pain medicine and physical medicine and rehabilitation (PMR), he has served as an assistant professor in the Department of Anesthesiology and Critical Care Medicine and of neurosurgery at George Washington University (GWU) Medical Center, Washington, DC. John Gulon, DDS, has served at Eden Prairie-based Park Dental since 1987. In addition to seeing patients at the group practice’s Roseville clinic, he has served as the president and CEO of Park Dental and its 37 practice locations since 2005. He graduated from the University of Minnesota School of Dentistry.

Michael Hu, MD, practices at Hennepin County Medical Center. He completed his medical degree and general surgery training at the University of Minnesota and his vascular surgery fellowship at Washington University in St. Louis. His professional interests include aneurysm disease, peripheral arterial and venous disease, carotid disease, and dialysis access. Derek Hustvet, RRT-NPS, LRT, is director of respiratory service at Pediatric Home Service (PHS). He earned a bachelor’s degree in respiratory therapy from North Dakota State University, Fargo, and is a licensed respiratory therapist and a neonatal/ pediatric respiratory care specialist.

Craig Johnson, PT, MBA, is president of the Minnesota Physical Therapy Association (MNPT), where he is active in government affairs and payer relations as well as strategic repositioning efforts, association payer forums, and payer relation meetings. He is also a partner and director of clinical integration at Therapy Partners.

Charles Sawyer, DC, is senior vice president at Northwestern Health Sciences University in Bloomington, Minnesota. During his 35-year career, he has been a leader in the chiropractic profession and a member of the faculty and administration at Northwestern Health Sciences University.

Gary Wingrove is director of government relations and strategic affairs for Gold Cross Ambulance/ Mayo Clinic Medical Transport in Minnesota and Western Wisconsin. He is a former Minnesota state EMS director who was awarded the Minnesota Department of Health’s Jim Parker Leadership Award for Community Health Services.

A bo ut th e Mo d e r ato r Mike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of MedFax, Minnesota Physician, Employee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.

Third Quarter 2015 Employee Benefits Planner


Minnesota health care roundtable Dr. Sawyer: Right now, with the fee-forservice reimbursement formula, we don’t have any incentive to talk about team-based care. If and when the payment shifts to focus on the value that the team provides, it will be more productive.

of-life measurements, like those used in Europe, and they’re not functionally based either. An outcome that’s worth measuring, in my mind, one that moves the health of the population higher, requires a functional measure and a quality-of-life measure. I think we do need to address that and not go with just process measures or measuring whether we get the person from point A to point B and they’re happy and out the door, but, rather, on their ability to function in society and their quality of life.

Dr. Desai: In 2018 it shifts, as Medicare makes the majority of payments based on value as opposed to fee-for-service. Mr. Starnes: What could be gained by better relationships between health care professional relationships?

Dr. Hu: In the large medical groups I’ve worked in, patient satisfaction is different from measuring the real outcomes—for example, that they’re functioning better, they’re able to walk, and they’re pain free. At the same time, you’re getting these little management metrics—for example, what would you as a physician do? Is the patient satisfied and happy? All of those are not necessarily the same as treating the problem. I think that trying to have patient satisfaction is a tremendous problem that a lot of physicians complain about in these large care systems, but it doesn’t necessarily correlate with better care.

Dr. Desai: Low-back pain is the single most expensive medical condition, with costs approaching around $100 billion annually in the United States. It’s three times more expensive than cardiac care services, and it’s more expensive than diabetes and cardiac care combined. Eighty percent of Americans will have an episode of low-back pain. However, it turns out that 7 percent of those patients—around 15 to 25 million Americans—are using up 85 to 97 percent of that $100 billion. If the different health care professionals treating these patients operated more collaboratively, there could be huge cost savings.

Dr. Desai: I agree with you, because when you look at the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, patients who are more likely to be satisfied are more likely to die earlier. Patient satisfaction and outcomes are not correlated. You’re more likely to provide more tests, more medications, more interventions for someone because then they feel

Mr. Johnson: I think that many of our current outcome measurements are really process measurements. They’re not quality-

“We are trying to promote innovative clinical pathways.” Craig Johnson, PT, MBA

as if something happened to them and they report being more satisfied—but that’s not the same as actually getting better. Dr. Hu: At HCMC (Hennepin County Medical Center), we’re working on a so-called Limb Salvage Center, where we have people from different specialties—radiology, vascular surgery, hyperbaric oxygen, dietary—trying to save limbs. All of us bring different perspectives, and maybe we have different tools. The whole goal is not to have two different ideas about how to treat this, but to have one consensus idea of how to treat the patient. Dr. Gulon: Certainly we’d see some advantages of interoperability between the medical record and the dental record. That doesn’t exist today. Instead we do it the old-fashioned way, with a call or paper referral. One challenge is to follow up to ensure that the patient did follow through with the referral with the physician. The other challenge is getting the results of that referral and/or the tests or evaluation back to the dentist. Mr. Starnes: Any other thoughts on how we could improve care by improving relationships between provider types? Dr. Gulon: One, for example, is periodontal disease. It’s present in roughly half the population today, and there are certain clear associations between periodontal disease and its management and cardiovascular health. Today, roughly 80 million people have some form of hypertension and 14.5 million people go undiagnosed or are unaware of the associated risks. Mr. Starnes: Are there examples from within your own organizations of how expanded relationships between different kinds of health care providers are producing good results? Mr. Wingrove: Within paramedic service, we have some high-utilizer groups of patients. The people that abuse our system tend to call on different days and at different times, so they’ll see nurse Judy on Monday and nurse Tammy on Wednesday and nurse Steve on Friday. North Memorial’s community paramedics now follow patients at home who have 10 or more medications, three or more comorbidities, and time-sensitive medications. The paramedics use the same electronic medical record, so they can see all the hospital visits, all the clinic visits, and can issue a request for a physical

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Minnesota health care roundtable therapy service or a secure message to the physician. It’s part of a Medicaid shared savings ACO (Accountable Care Organization), so the state gave them a significant portion of shared savings last fall. Of course, 80 percent of it should go to the paramedic and 20 percent be shared by the rest of you, but that model is a shining star in the country. Dr. Sawyer: The Hennepin Health initiative is extremely novel. It combines the clinical services that we all think about, but then it adds social services, and throws a big net over the most complicated, vulnerable population of patients where the costs are high and the access is not good. They’re bringing mental health professionals and social workers in and dealing with poverty and homelessness. Mr. Hustvet: We are trying to have more proactive team involvement. We are also trying to prevent emergency room visits and the expense of Medicare dollars. We do this not just with asthma and obesity but also with our general patient population. The bigger challenge is when we have to communicate with four different physicians from two different hospitals, with one to four involved parents, and three, four, or five different primary nurses. Care conferences are probably a great example as well. We get to sit with the physicians, with the family, with everybody involved and have a conversation. These meetings can sometimes raise really important, crucial questions. If the discharge is tomorrow, what happens, how do we fix this, do we rush through things? If the team does save dollars, it’s hospital-based versus home care versus maybe an extended living facility, that determines where that benefit goes. Mr. Johnson: What’s going well? Here are a few examples. One is a primary spine program in Mankato. The primary care clinic is a medical home, and they’re using a tool to risk-adjust patients in terms of the risk of accessing services and making referrals to physical therapy. Another therapy clinic in our network is working with a primary care clinic, and when a patient is identified with prediabetes based on blood work, they refer them to physical therapy for education. They’ve shown very good results in reducing blood sugar levels over a six-month period. Finally, Courage Kenny set up a pilot program a couple of years ago as a medical

home with about 200 patients. The patient population was essentially defined as dual eligible, which means they are eligible for Medicaid and Medicare. By being very preventivefocused and “We are trying to helping manage have more proactive their health, I believe they team involvement.” saved the state Derek Hustvet, RRT-NPS, LRT about $2 million. Mr. Starnes: Why are health plans so unwilling to offer fair compensation to non-physician health care professionals? Dr. Sawyer: It’s all about coding and chasing the money. We’re starting to ditch the terms complementary and alternative because they don’t mean anything. If acupuncture is the best early treatment to use, along with reasonable medication management for a patient with acute or chronic pain, then that should be put into effect right from the start. Typically, to qualify for reimbursement for acupuncture the pain has to be four months of chronicity or longer. This delays the use of a therapy that has no downside to it whatsoever. Then, once payment is approved, reimbursement is so low that it’s not feasible to provide the care in a pain clinic or large health system. Mr. Johnson: In our current fee-for-service system it’s obvious that the current pathway for most disease processes is too costly. We’ve done a fair amount of research into payer data of delivery partners and timing of care in relation to physical therapy and particularly musculoskeletal conditions, and there’s a huge amount of care that’s provided upstream. There have been a couple of very good research articles from Spine magazine and Health Affairs demonstrating that early access to physical therapy for low back pain—within 14 days of seeing a primary or a medical provider— has reduced the total episode cost for that back episode by 40 percent. Mr. Starnes: Dental insurance reimbursement seems to differ from other reimbursement models. Why is this?

Dr. Gulon: I’m not sure that dental is doing it any better. In fact, in dental we get paid by procedures. In the dental world, we don’t operate with diagnostic codes, but that world is evolving. On the other hand, we’re working on a couple of novel projects with integrated physician networks, including some sleep studies right in our practice. We’ve worked out some reimbursement mechanisms between the physician network and our group. Mr. Starnes: One of the biggest challenges comes from corporate culture and senior leadership. In some systems individuals won’t change regardless of evidence that suggests they should, and in some systems senior leadership is very proactive about change but it somehow gets bogged down in mid-level management. Any comments on this? Dr. Desai: We do have progressive-thinking leadership, and we’re doing some things that are progressive and innovative on the training level. People who have been trained already and have been out of school, for five, 10, or 15 years, is where the gap is. What we really need is to identify and mentor and support great clinical leaders. What I mean is that health care is not going to change until health care providers buy in. You can have a great administrator, you can force it down someone’s throat, but you need a foil to that with great health care

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Third Quarter 2015 Employee Benefits Planner


Minnesota health care roundtable

“Everybody ought to be right at the top of their license.” Charles Sawyer, DC

leadership. Getting folks who are mid-career to change their practice patterns, as we’ve all been talking about, is a significantly greater challenge because they’re set in their ways. Those are the folks running the show, so to speak. Dr. Gulon: I’m really optimistic that the ears are open from the medical administrators’ point of view. Many of us have been proud that in Minnesota, overall, we’re pretty progressive with regards to health care. Unfortunately, when it comes to the pediatric dental benefit, Minnesota is dead last, 50th out of 50, in terms of reimbursement. Switching gears for a moment, from the conversations we’ve had with chief medical officers, there’s a significant amount of waste in terms of the access for dental care through emergency departments, with roughly $50 million each year being spent on dental care in emergency rooms. Interestingly enough, we’ve been able to partner with a physician group to leverage some of the synergies so that we can actually have those patients access the care through the dental practice rather than through the emergency room. Mr. Wingrove: When we encounter a patient who has congestive heart failure and has significant breathing difficulty, we have two choices. We can intubate them, or we can put them on CPAP (continuous positive airway pressure). If we intubate them, what do you suppose happens to the hospital-

acquired infection rate? It has nothing to do with the hospital, but it’s in an unsterile environment, and it’s an invasive procedure. On the other hand, if we use CPAP and maybe even get a better result than intubation, we can drive the hospital score into a better position. Those are some of the things that have value to patients as well as to the payers. Mr. Starnes: Under the Accountable Care Act (ACA), reimbursement for health care services will migrate from a volume- to a value-based methodology. How does expanded collaboration between health care professionals respond to this migration? Mr. Johnson: The whole notion of collaboration has been spurred on by the ACA. The Centers for Medicare & Medicaid Services (CMS) has announced that they’re moving towards 50 percent of their payment being value-based by 2018, and that will certainly foster innovation around collaboration. I am a firm believer that we should manage what we measure, so measuring outcome is going to be very critical in this collaboration. Financial incentives, when they are aligned, will also drive collaboration, and financial incentives really do drive our provider behavior. Mr. Starnes: Part of the health care reform is going to deal with attempts to reduce rehospitalization. How can penalties for rehospitalization drive better collaboration?

Mr. Hustvet: From a home care perspective, we actually have some incentive right now to keep patients out of the hospital. We can’t bill for our equipment, and we can’t bill for the pieces or parts or supplies they use if they’re in the hospital. We have a clinical piece that often does not get reimbursed. If it does get reimbursed, it’s not a full reimbursement, but that piece of equipment is necessary to keep that patient out of the hospital. We’ve noticed, in the last three years, more focus from the hospital facility level at care management and discharge planning. There’s a lot more focus on providing 24-hour, 7-day-a-week support. There used to be just a daily discharge plan, after which you didn’t have a lot of communication and cooperation. I think from our perspective, we’ve been trying to do this because it’s good for our business model and it’s good for our patients. Mr. Starnes: Can an increased emphasis on prevention foster improved collaborations? Dr. Desai: It’s very unlikely that prevention can be achieved with just one provider. It’s unlikely that just one specialist or one primary care provider could achieve prevention. I think that in itself provides the foundation for greater collaboration. One of the things I tell patients all the time is, I don’t have to be the one to fix you, I don’t have to be the one to make you better, but if I can get you to the right person, it still makes me look good. Dr. Sawyer: I’m not sure who is able, by virtue of their training and experience, to actually provide preventive services. I’m not talking about pap smears and mammograms, I’m talking about the discussions, the coaching, and visiting with the patient. We’ve got a mixed bag, and I think it’s too early to know for sure how that’s going to work, but we certainly have to put that in place because it’s now mandated. Mr. Starnes: Are there future legislative actions at the state or federal level that might drive collaboration? Mr. Johnson: It can be demonstrated that silo management mentality is ineffective. From our association’s standpoint, we are trying to promote innovative clinical pathways, and research has shown that early access to physical therapy is key to saving dollars throughout that whole episode. We have a very innovative national association.

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Employee Benefits Planner Third Quarter 2015

Minnesota health care roundtable I applied for a grant from them to run a pilot study around worker’s compensation patients directly accessing physical therapy. We have had discussions with stakeholders at high levels including the Chamber of Commerce, the Department of Labor, brokers, and the worker’s compensation insurer for the state. I think this is definitely beginning to show up on their radar. I think that will obviously affect future legislation and the way that the worker’s compensation fee schedule works. Ultimately, we are hoping to change legislation. Mr. Starnes: We recently had landmark approval from the House and Senate on new Medicare reform. Is Medicare reform going to help foster better relationships between health care professionals? Mr. Hustvet: I think it’s a good start. I think anytime you’re getting physicians involved with alternative providers, there’s going to be more collaboration. There’s a push right now on both physicians and even physician assistants to see how much work they can get done. If we can spend 10 minutes, 20 minutes, or a half hour with the patient and then have a five-minute conversation with the physician—versus the physician only getting five minutes with the patient—​ I think that’s going to drive a little more collaboration, and offer a little more exposure. The physician, I think, will end up ultimately being more of a coordinator and manager of the other therapies and services. Mr. Starnes: In every legislative session, there are bills introduced that redefine the scope of practice for specific provider types, and there are always “turf-war” conflicts over their passage. How do we best address this? Mr. Wingrove: Sometimes that’s healthy tension, and sometimes that’s not healthy tension. We’re in a time when change is here and it’s being made everywhere, and I think we just have to recognize there have been changes over time in all of our professions, and those are cyclic. This is a new time when the professions will change. Technology also plays a role in how safely different providers can do different things. The professional protection, I don’t think, will ever go away, but we’ll have to respond to it based on what the payment system forces on us. Mr. Johnson: We don’t really like this licensure turf battle, but it does happen. There’s

a filter that describes scope and helps legislators make decisions. Legislators make decisions about scope for every profession in this state, and they’re not really the experts most of the time. They’ve actually appreciated that here’s something that you can measure when somebody comes to you and they want to expand in a certain area. I think we need to get beyond that as well and be very proactive, because the time that it takes and the resources it takes to fight those battles are pretty wasted. I think we need to recognize that and try to maximize the training level of each provider on the care team and not have legislative turf battles about scope. Dr. Sawyer: The real issue is that everybody ought to be right at the top of their license, and if these care models can change and the reimbursement can change, then the commercial payers will follow what Medicare is doing. Getting this shift to value would allow clinicians like Gary and me to sit down at the table and say, well, if we’re in the shop together, if we’re in the same practice together, what can we do to elevate the model of care and the delivery of it and the efficiency of it and go right to a payer, along with nurse practitioners, pain specialists, and acupuncturists and say, we’ve got a proposal from you and it’s too good to turn down.

point, I believe that fee-for-service can be a very powerful motivator sometimes just to do the work. Will people work as hard when you take away some of that financial incentive? I know that under different health care models and within different health care groups, when you incentivize doing a procedure and you’re a subspecialist, you do make your people work harder. When you take that incentive away, they don’t work as hard. Dr. Sawyer: I do worry a little bit about the fact that maybe we’re over-vilifying feefor-service reimbursement. If we shift into value-based reimbursement and shared savings and shared risk, I wonder if there’s going to be another perverse incentive. If I do less, the team that I’m on, the hospital that I practice in, and the system that I’m a health care provider in, is going to do better, and by extension I will do better if my contract shows some performance. Mr. Hustvet: I think there’s also potential for cost savings. If I’m a respiratory therapist and I’m allowed to manage an asthma patient, more than likely I’m going to get reimbursed less than the pulmonologist would. I could be working for a pulmonologist or a physician or a primary pediatrician through their office. I’m getting reimbursed less but they’re seeing three times as many asthma patients because I’m there as well. I think there’s some potential to shift some

Dr. Gulon: Dentistry, as I mentioned earlier, has added mid-level practitioners in the form of dental therapists and advanced dental therapists with expanded functions. Dentistry was not unlike other professions “We’re in a time that were slow to when change recognize the shortagis here.” es that we are encountering. We have to be Gary Wingrove more creative, and I think that’s driving a lot of the behaviors out there. Dr. Hu: If you can get the collaborations to work, is it going to be revenue neutral? If it’s revenue neutral, basically you’re redistributing income from one group to another group. From a practical stand-

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Minnesota health care roundtable of the work to me, or other folks that aren’t billing quite as much, and still see quality patients and allow the physician to see the higher-needs patients that maybe are getting delayed or pushed off or even going into the hospital. Mr. Starnes: An emerging model involves community-based initiatives, many of which could be duplicated and expanded. Can you give some examples? Mr. Wingrove: Our state got a grant from CMS to work on different sorts of models, and one of the ones they’ve chosen is to create opportunities to expand three emerging professions: community paramedics, community health workers, and dental therapists. They are contracting now for each of these to create tool kits for potential employers. The goal is to speed the adoption of the professions by employers. It will set the stage for the employer to learn about the training they come in with, the sorts of things you can expect them to do, and how reimbursement works—if it works at all. They are also, at least in our case, subsidizing the employment of a handful of professionals so that employers can test it out and make sure it works and learn about the intricate details of actually putting the profession into practice.

Dr. Sawyer: I’m not sure that the innovations would have happened in either the state innovation model initiative or the Hennepin Health initiative if there hadn’t been legislation and direct involvement by state agencies with provider groups. In other words, I’m not sure that would have evolved or happened if the payers weren’t the ones responsible for it, and I don’t think they would’ve taken the initiative. Mr. Johnson: Under one community-based program that, in its original form, our association worked on, we developed an education program that assessed seniors for their risk of falling. Reducing the number of falls has an impact on that individual’s health as well as on the health of those in the community. The program was first developed for assessment and then for intervention, and oftentimes the assessment revealed that a community-based strengthening program would help to reduce the risk of falls. This was a grant-funded initiative with a trainthe-trainer model, which trained community health nurses and others to assess and then to address the issue. Now the Department of Health is reviving this initiative, with about a dozen health care providers and community organizations working on reducing falls by seniors in the community.

“I see this as an opportunity, not a barrier.” John Gulon, DDS

Mr. Starnes: How could a value-based care model promote interprofessional relationships or address the turf or silo mentality? Dr. Desai: The greatest advantage of a value-based reimbursement model is that, for the most part, the value of a person’s contribution to the care team gets equalized a little bit better. The traditional system is quite hierarchal, with certain people on the top and others along the way. By bundling care and by providing reimbursement in a value-based system, long-term management becomes more important than incident-based management, which also then shifts away from the silo effect. Mr. Starnes: If we increased the focus on the patient experience, might we break down some of that silo mentality? Dr. Hu: I think so. Like anything, you want to do the best thing for the patient, and it’s rare that you’re the only one who can do it. I think centering on the patients, giving them the best experience, requires you to seek out all the other things that they need. I think, yes, that will help break down some of the silos. Dr. Gulon: Patients who go through different levels of care—whether it’s with a dentist or a physician or a chiropractor or whomever—will benefit if there’s a high level of transparency, communication, and coordination within the care team. Certainly we recognize the challenges of achieving that, but also it’s pretty obvious how that might feel to the patient. Mr. Starnes: Even though different types of providers have similar goals, they may not talk to each other. Why not? Dr. Desai: Synergies are often unrealized because of time and malaligned financial incentives. Those are the two primary reasons. Right now there’s no incentive to learn what the other guys do. He might be the specialist in this, I might be the specialist in that. In order to get that 360-degree view or that spherical view of what the patient’s going through, you need to get all partners involved. If you do that, then the value of your partnership increases and your incentive to learn about what others do, at least to some extent, increases. Dr. Sawyer: If we’re in the same practice business together, we sit down at the table and figure out how are we going to be

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Minnesota health care roundtable successful, because we’d like to approach this particular payer, public or private, with a proposal to do X for a new model of care and delivery. We’ve got to get to know each other, on both a professional level and a personal level, so we have some trust and assurance that we’re watching each other’s backs. Being in business together is a big deal.

“I tell patients all the time, ‘I don’t have to be the one to fix you.’” Mehul Desai, MD, MPH

Mr. Hustvet: We lack easy communication and easy access tools. Just because I’m only free at noon and you’re only free at one doesn’t mean I couldn’t have gone into a shared system and put in a note or a comment for you. That’s better than a system in which one physician calls, one emails, and one faxes or leaves a note on the nurse’s desk. I can’t communicate with three or four of the hospitals that use different electronic records, and one physician who prefers to use a pager and calls me back when I’m already out on the road seeing somebody else. Mr. Starnes: Do patients need to be educated not to fear being part of a collaborative process? Dr. Desai: I think so. I think, increasingly, you have patients who have been exposed to advocacy groups. Also, patients are increasingly more educated about their disease states. Patients come to me all the time and say, well, PT (physical therapy) doesn’t work for me, or chiropractic doesn’t work for me, or acupuncture doesn’t work for me. That ties back into that initial conversation we had about training and understanding what your collaborators bring to the table. I say to the patient, well, it’s not that PT doesn’t work for you, but it’s that therapist. Mr. Johnson: I think that’s exactly right. We have a joke in physical therapy about a patient making a comment to the doctor: “I tried physical therapy, and it didn’t work.” The comeback is, “Have you tried doctoring?” It’s the individual. There is a provider in town that is absolutely selective about which therapist he sends his patients to because he’s taken the time to build a relationship. Understanding the person who’s delivering the care is really critical, and I think that’s a great point. Dr. Desai: A lot of us who believe in multidisciplinary or interdisciplinary care have taken the time to create our own networks. I have already identified the folks I’m going to

send people to. I have preferred providers, and those are the only people I’m interested in sending patients to if I have a choice. I know at the end of the day, the patients are going to get better, and it’s going to make me look good, and everyone, so to speak, is happy at the end of that experience. Mr. Starnes: What must be done to expand interprofessional relationships in health care delivery? Mr. Wingrove: I think it centers on the people and the relationships between the professionals. It will go faster if we spend time on the front end managing that process well. Mr. Hustvet: I think the most basic piece is just increased communication, whether that involves meetings, discussions, or electronic communications. That’s really going to be the main driver. Dr. Desai: In my estimation, it’s financial misalignment. Until we align the financial incentives to collaborate, there’s going to be some resistance. I think that with the Accountable Care Act and with value-based reimbursement, we’re moving in the right direction, and I think there are some really creative ideas with regards to that, but finances need to be aligned.

Dr. Sawyer: I think it has to be initiative and motivation. In other words, when I’ve got a reason to reach out, I should make that phone call or send that email and ask if we can have lunch so we can start talking about some different ways of working together. Dr. Gulon: From the consumer point of view, I would ask patients to continue to access the system and to understand how relationships and overall health are interconnected and to continue to demand from the medical care system that which seems obvious but which may be more difficult to achieve. I think that with continued persistence, that will happen. Dr. Hu: If I had to pick one, I would say good communication between the different specialties and the different providers. Concurrent with that would be a good understanding of the capabilities of everyone on the team and what they can do for the patient. Mr. Johnson: I would echo those. It’s a long list, but I believe that aligning the financial incentives and relationships and understanding what each provider does are most important.

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Ad m i n i s tr ati o n


benefit administration The advantages of Taft-Hartley plans By Andrew Staab, JD


orporate human resource departments seem to run smoothly until a question arises involving a Taft-Hartley fringe benefit plan. (“Fringe benefit” refers to non-wage compensation, including health insurance.) This is unfortunate, because Taft-Hartley fringe benefit plans have been around since the late 1940s, yet, they still seem unfamiliar in the corporate human resource universe. There are ways to improve interaction between HR decision-makers

and the third-party administrators that manage the daily operations of these plans, and this article will discuss them. Taft-Hartley plans in a nutshell Taft-Hartley plans are employee pension, health, and other welfare plans created by the federal law called the Taft-Hartley Act of 1947, also known as the Labor-Management Relations Act. One of

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the congressional goals of this legislation was to restructure fringe benefit plan administration, because the previous structure had been ineffective in preventing corruption among organized labor and employers. To address this concern, the Act requires that employee benefit plans must be administered by a board of trustees, half of whom are appointed by “labor” and the other half appointed by “management.” (These terms are generic references to unions and/ or employer associations.) This equalizes the board’s administrative foundation so that neither labor nor management has an advantage with respect to plan assets. These plans are unique in that they result from collective bargaining between organized labor and employers.

to the Taft-Hartley plans are spelled out in the CBA, and an employer’s deviation from that written agreement will result in a federal labor law violation. The following example illustrates how a human resource department could unintentionally violate a CBA: The CBA requires the employer to contribute to the Taft-Hartley health plan monthly, with a payment date on or before the 15th day of the month after the work was performed. The employer’s payroll program, which covers fringe benefits, is established to pay employees every two weeks. Accordingly, the employer submits hours and contributions to the Taft-Hartley plan for four weeks instead of one month. If an employee’s continued eligibility to participate in the health plan is dependent on a minimum number of hours during a month, then the practice of submitting hours and contributions for only four weeks could result in the employee losing eligibility in spite of the employee’s actually working the required number of hours for the month.

Taft-Hartley plans are administered by volunteer trustees.

Taft-Hartley plans are administered by volunteer trustees appointed by either labor or management. Under another federal statute, the Employee Retirement Income Security Act (ERISA), plan trustees have a fiduciary duty to act solely for the benefit of the employee benefit plan and to monitor the plan’s reasonable expenses. Most plan trustees are not experts in pensions or health insurance, so in order to fulfill their statutory fiduciary obligation they retain attorneys, accountants, consultants, actuaries, and administrators.

Taft-Hartley/HR interaction Taft-Hartley plan trustees rely on the plan’s administrative office to perform the plan’s daily functions such as paying claims, determining eligibility, and processing employer contribution payments. This office can exist either as an independent third-party administrator (TPA) or as a specific, non-TPA office dedicated to the plan’s administration.

The employer’s payment of two two-week periods is in violation of the CBA, and could be charged as an unfair labor practice under the National Labor Relations Act. Additionally, the employee’s claims for health benefits likely would be denied due to loss of eligibility. Finally, Taft-Hartley plan fiduciaries have a fiduciary obligaSimplify benefit administration to page 26

In the next issue...

The non-TPA office is staffed by the same kind of people who work at a TPA office. Often, the non-TPA office is staffed by people closely related to the specific trade whose plan it administers, including people who have left the trade because of a work-related injury. It’s noteworthy to mention, however, that a TPA office typically administers Taft-Hartley plans for a variety of trades or employers, while a non-TPA office focuses on administering plans within a specific trade. Regardless of the type of Taft-Hartley plan administration, human resource executives should contact the plan’s administrator to facilitate effective communications and relations with the Taft-Hartley plan. It is not unusual for the Taft-Hartley plan administrator to perform many of the human resource functions that are already being done within a company’s human resource department, such as processing COBRA notices and HIPAA certificates. In the Taft-Hartley universe, the plans take on an employer’s administrative roles with respect to issues of federal regulatory compliance. It is crucial for the plans and the employers to coordinate administrative functions to eliminate duplication or inconsistent communications to plan participants. Collective bargaining agreements Human resource departments often find it difficult to adapt to a collective bargaining agreement (CBA) with a labor union, particularly with respect to fringe benefits. The employer’s payment obligations

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Simplify benefit administraion from page 25

tion to collect from the employer a perceived underpayment for the month. No employer would like to face these consequences due to a failure to acknowledge the frequency of fringe benefit contribution payment obligations. Successful communication The previous example of an HR department’s inadvertent mistake leading to serious legal and financial consequences could have been avoided by better communication between the human resource decision-makers and the TPA. One strategy for maintaining effective communication is used by a TPA in Minnesota that recognizes the need to keep communications flowing with its corporate employers that contribute to Taft-Hartley plans. This TPA takes the initiative to contact the human resource executives at the employers that use its services, by inviting them to regular educational sessions. These information sessions are directed not only to plan participants but also to company human resource officials. The TPA’s rationale for doing this is that these information sessions help it do its job better and more efficiently. Another strategy for fostering communication is used by a Taft-Hartley plan administrator in California, which invites employers to come to the plan’s administrative office to take a tour and see how the plan operates.


Employee Benefits Planner Third Quarter 2015

These examples of successful relationships between HR departments and Taft-Hartley plans are not difficult to replicate. Although these examples were initiated from the Taft-Hartley side, there is no reason human resource departments cannot contact their plan’s administrative entity to promote communications. Additionally, human resource departments can coordinate with Taft-Hartley plan administrators to stage benefit fairs for their employees. A proven HR partner The beauty of Taft-Hartley plans is that much of the HR work ordinarily associated with single employer plans is removed from an employer’s responsibility. Many employers enjoy the fact that Taft-Hartley plans free them from having to shop for health insurance or retirement plan providers. It’s all built in for employers with a Taft-Hartley plan. All the employer has to do is to adhere to the payment obligations spelled out in the CBA. Taft-Hartley plans have been in existence since 1947, will be around for many years to come, and can successfully co-exist with companies’ human resource departments. (Special thanks to Cullen Garrity and Dave Danley at WilsonMcShane Corporation, a third-party administrator in Bloomington, Minnesota.) Andrew Staab, JD, recently retired from Felhaber Larson, a Twin Cities-based firm specializing in labor and employment law and employee benefits.

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Third Quarter 2015 Employee Benefits Planner


Temporary workers from page 15

is responsible for recordkeeping. When the staffing agency and host employer share supervisory roles, OSHA advises that the two employers reach an agreement regarding safety and health responsibilities, including recordkeeping. Recommendations Staffing agencies and host employers should follow these best practices: 1. Temporary staffing agencies and host employers should state their respective safety-related responsibilities in their contracts with each other to ensure clear understanding of each employer’s role. Neither party can contract away OSHA obligations, but a clear contract helps avoid having duties falling through the cracks and helps defend citations. 2. Both employers should conduct new hire/new project safety orientations.

 ost employers should evaluate whether temporary workers 5. H may be viewed by the Department of Labor as the employer’s actual employees. A host employer’s responsibilities are different and more extensive if a temporary worker is treated as an actual employee. If the worker is considered an actual employee, safety-related responsibilities are no longer shared by the host and staffing agency and all shift to the host employer. Just because a host employer or a contract says that a worker is a contractor/temp does not mean that a judge would classify the worker that way. If you hire temporary workers The five most frequently cited OSHA violations at workplaces using temporary workers: • Lockout/tagout

• Hazard communication • Electrical hazards • Forklifts and other industrial vehicles

3. Both employers plus the temporary workers should maintain open communication to ensure injuries are promptly reported and reviewed and underlying hazards are corrected.

This list is training-focused because OSHA believes host employers deliberately avoid investing in training for temporary workers.

4. Staffing agencies and host employers should both perform a worksite assessment to determine what hazardous conditions exist at the host employer’s worksite and how best to ensure temporary workers’ protection.

Eric J. Conn, Esq., is a founding partner of Conn Maciel Carey, Washington, DC, and chair of the firm’s national OSHA practice group. Lindsay A. Smith, Esq., is an associate in the firm’s OSHA and Employment practice groups.

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Department of Labor audits from page 13

plan, which was a limited partnership with high earnings in recent years. And, the plan had a large number of loans. Any of these items could have triggered an audit. During the audit, the TPA responded directly to requests from the DOL agent for information and documents, making the process more efficient for the plan sponsor. The audit was conducted via phone, email, and postal submission. After six months, the DOL issued a closing letter. The plan sponsor had to recalculate some of the lost earnings caused by the late deposits, remit these earnings to the plan, and allocate them to affected plan participants. The remuneration was nominal, most likely because the plan sponsor had taken corrective action prior to the audit, could demonstrate improved processes and procedures, and responded immediately to the audit request.

Cooperate, communicate, coordinate

What to do

The DOL wants all qualified plans to be in compliance with ERISA laws and for plan participants’ assets to be protected. Audits are not uncommon. Plan sponsors subject to an audit who are in compliance with the rules will generally find that the DOL identifies only minor deficiencies. While time consuming, a well-run plan typically completes an audit without a fine or civil complaint. Plans identified as having more serious deficiencies can improve their audit outcome by being truthful and taking immediate steps to remedy any issues identified by the DOL. Ellen Nipp, QKA, is a manager, Retirement Plan Solutions, at Bronfman E. L. Rothschild, Minneapolis, a registered investment advisor. She earned the Qualified 401(k) Administrator designation, QKA, through the American Society of Pension Professionals & Actuaries, ASPPA.

Third Quarter 2015 Employee Benefits Planner


Overseas work from page 11

care requirements, and U.S. consular assistance for obtaining passports for children born abroad. Timing is everything Unfortunately, one of the most important factors, timing, is often outside most employers’ control. Processing a work permit typically takes weeks—more often, months—before it is secured. There also may be in-person visa interviews, police clearance checks, and medical exams required before final permission is granted. Begin any supporting work for a global transfer as early as possible to prepare for possible delays in visa issuance, work permit denials, and unforeseen emergencies. Duration Each country has its own laws governing how long foreign employees may work and reside. Some provide for limited renewals on an annual or biannual basis. Others expect the employee to begin the path to becoming a resident in order to maintain a work permit. Understand what options are available to determine how long an assignment can last. Case study: Mexico As in most countries, the procedure for a foreign employee to legally work in Mexico varies depending on the specifics of the employment. Mexican entities that hire foreign workers are subject to different rules than U.S. entities that send foreign employees to perform

supervisory duties in Mexico. For U.S. companies with a Mexican subsidiary, the first step in obtaining a worker’s visa is to register the subsidiary with Mexico’s immigration authority (“INM”) as an employer. Once the Mexican entity is registered (which can take 30–60 days), the Mexican subsidiary must request that the INM grant a visa authorization to the foreign employee. The authorization is then issued to all Mexican consulates worldwide, allowing the applicant to schedule an interview with a Mexican consulate to request a visa stamp. The final step involves exchanging the visa stamp for a visa card at the local INM office in the Mexican state in which the employee will work. This must be done in person and may involve follow-up visits to the INM office. The worker’s visa may be issued for up to four years at the INM’s discretion. The employee’s presence in Mexico for more than 183 days of any year will make the employee subject to taxation in Mexico on worldwide sourced income. In addition, because the entire process from employer registration to receipt of the visa card can take up to four months, it is important to plan ahead. Debra Schneider, Esq., is an officer of Fredrikson & Byron, PA, Minneapolis, and Aleida Ortega Conners, Esq., is an associate of the firm in the same office. Conners works in the firm’s International Group and Schneider works in its Immigration Group.

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MN Employee Benefits Planner 3rd Qtr 2015  

Minnesota Employee Benefits Planner — Third Quarter 2015 | Volume 22 No. 3 | INTERVIEW — PrimaCare Direct: A health care cooperative | Matt...

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