__MAIN_TEXT__
feature-image

Page 1

JUNE 2021

A S I P C P U B L I C AT I O N

SIPCONLINE.NET

Rx Cost Remedies on the Horizon SIIA’S DRUG PRICING TASK FORCE BENCHMARKS STRATEGIES ACROSS THREE CRITICAL AREAS TO MOVE THE NEEDLE ON COST-CONTAINMENT


Strength In Balance Let MidLands Provide an integrated aPProach to seLf-insured soLutions

Experts in coverage solutions for single entities, groups and public entities, our integrated approach gives self-insureds greater stability and control over their self-insured plan. Unparalleled underwriting expertise, innovative risk management and in-house claims management, work in sync and in perfect balance for best possible outcomes.

800.800.4007 midlandsmgt.com publicentity@midman.com

WORKERS’ COMPENSATION | PUBLIC ENTITY | CATASTROPHIC CLAIMS MANAGEMENT | THIRD PARTY ADMINISTRATION | EXCESS WORKERS’ COMPENSATION | AUDITS | COMMUTATION | UTILIZATION & REVIEW


TABLE OF CONTENTS

JUNE 2021 VOL 152

W W W. S I P C O N L I N E . N E T

FEATURES 4

RX COST REMEDIES ON THE HORIZON

SIIA’S DRUG PRICING TASK FORCE BENCHMARKS STRATEGIES ACROSS THREE CRITICAL AREAS TO MOVE THE NEEDLE ON COST-CONTAINMENT

By Bruce Shutan

12

SPOTLIGHT INTERVIEW: DR. ROBERT LORENZ, M.D.,

NETWORK SERVICES, CLEVELAND CLINIC, DISCUSSES

M.B.A., EXECUTIVE MEDICAL DIRECTOR, MARKET AND QUALITY HEALTHCARE, SERVICES AND RELATIONSHIPS IN THE MEDICAL TRAVEL AND TOURISM INDUSTRY

ARTICLES 20

DEVELOPING ISSUES CHALLENGING THE

CAPTIVE INDUSTRY

26

PENSION RULING LIMITS HEALTH PLAN MISMANAGEMENT CASES

34

SIIA ENDEAVORS

50

NEWS FROM SIIA MEMBERS

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688

Self-Insurer’s Publishing Corp.

PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary

JUNE 2021 3


F E AT U R E

Rx Cost Remedies on the Horizon SIIA’S DRUG PRICING TASK FORCE BENCHMARKS STRATEGIES ACROSS THREE CRITICAL AREAS TO MOVE THE NEEDLE ON COST-CONTAINMENT

Written By Bruce Shutan

T T

he high cost of prescription drugs, particularly specialty scripts, has long been top of mind across the self-insured community. But SIIA’s Drug Pricing Task Force is poised to help allay growing concerns about managing eye-popping Rx claims.

“one of the larger claim categories that we pay as a stop-loss carrier,” reports Shaun Peterson, VP of stop loss for High-cost drugs are

Voya Financial who chairs the task force and is also on SIIA’s board of directors. He recalls multimillion-dollar cell and gene therapies emerging as a huge concern in

“From there,” he says, “we expanded to all drugs in excess of $250,000 in a year” as a

2019 when the Rx task force began to take shape.

wider area to target. As leader of the task force, Peterson’s role is as a facilitator of industry experts who are divided into subgroups that tackle three key areas: plan documents, roles and responsibilities, and finances. They include clinicians, brokers, stop-loss carriers and TPAs, as well as claims and pharmaceutical management firms. Their mission is to produce a usable resource or tool in time for SIIA’s national conference in the fall to help members effectively manage their pharmaceutical spend. Materials from all three working groups were recently merged into a single document, though it was unknown as this issue went to press exactly what form the final draft would take.

4

THE SELF-INSURER


Rx Cost Remedies EYEING BEST PRACTICES The hope, he says, is to raise awareness around the importance of having a governing document with solid language in place that stipulates how the plan is going to be administered with specific recommendations for how it can be used to help drive better drug utilization. In terms of roles and responsibilities he notes that the goal is to clearly define what’s expected of pharmacy benefit managers (PBMs), medical Shaun Peterson providers, brokers, TPAs, stop-loss carriers, other partners and self-insured employers themselves. Finally, on the financing piece the focus is leveraging the plan document with clear roles and responsibilities for all parties to increase efficiency in the delivery of high-cost pharmaceutics. Drug pricing is an issue for which SIIA can advocate on behalf of its members as Congress considers legislation in this area, explains Ryan Work, SIIA’s VP of government relations. But at least initially, he describes the nearly 20-member Rx task force as a means to address industry challenges

“with or without

legislation and policy changes.” The ultimate aim is to produce a bestpractice document that can be customized to each employer’s needs to maximize the efficiency of their drug spend. Work says key components may include anything from suggesting low-cost, efficacious alternatives to prescribed drugs and finding the most appropriate treatment to implementing step therapies and recommending a whole mode of different action items.

Ryan Work

UNDERSTANDING FINANCE Specialty drug costs have become unsustainable – a price-tag that’s escalating with more scripts in the development pipeline, according to Steve Kelly, chairman and co-founder of ELAP Services whose task force subgroup’s focus is on the area of

“We think it’s a clear and present danger, and how we face this as an industry is critical,” he says.

finance.

Drugs like Spinraza and Zolgensma “knock the actuarial framework of the self-funded plans sideways,” Kelly observes. “There’s no way to really build that into the cost of American health care. As these drugs and remedies become more prevalent, it’s going to crowd out other areas of spending. They’re incredibly effective and bring incredible promise, but they also bring unsustainable costs.” Across several specialty drug categories, lives hang in the balance. Four or five years ago, for example, Peterson says there was no treatment for spinal muscular atrophy, which was the leading congenital cause of infant mortality. Then along came Spinraza at an estimated cost of $350,000 a year for a maintenance dose, followed by Zolgensma at about $2.1 million for a single dose that’s theoretically curative and not requiring additional treatment. The proliferation of specialty drugs has elevated the importance of Rx cost-containment strategies for stoploss carriers that are trying to better manage catastrophic claims for their self-insured employers, explains Jeff Gavlick, SVP of accident and health at Tokio Marine HCC’s Stop-Loss Group, whose task force subgroup’s focus is on plan documents. Complicating matters is that annual and lifetime maximums were removed from health plans under the Affordable Care Act, and as a result, stop-loss carriers are bearing the brunt of any very large, and often ongoing prescription drug claims. While there are currently fewer than 10 cell and gene therapies approved by the Food and Drug Administration, Gavlick

JUNE 2021

5


Utilization

Quality

Cost

Bring balance to your health plan Improve Quality, Manage Utilization, Reduce Cost

The long-term financial security of your medical benefit plan depends on managing much more than the cost of care. Let Vālenz® lead you to the perfect balance between quality, utilization and cost. By gathering and analyzing millions of data points within the Valenz ecosystem, we enable you to make better decisions that control costs while empowering members to lead strong, vigorous and healthy lives. We help you manage the full continuum — from pre-claim losses through postclaim resolution — offering transparent, data-driven collaboration with members, providers and payers to keep you on the path to smarter, better, faster healthcare. Visit valenzhealth.com or call (866) 762-4455 to bring balance to your medical benefit plan.

23048 N 15th Ave., Phoenix, AZ 85027 • (866) 762-4455 • valenzhealth.com Proud to be a Diamond Member


Rx Cost Remedies cautions that the number could surpass 50 within a few years. Describing the FDA approval pipeline as “frightening,” he sees dozens of so-called orphan drugs that target medical conditions for very

protect them from a catastrophic claim perspective.” Adds Marien Diaz, VP of excess loss claims at Symetra Life Insurance Company, whose task force subgroup’s focus is on the area of roles

“I think the focal point for many of us in the task Marien Diaz force is oncology drugs. There’s been tremendous innovation in that space.” Apart from that, she

and responsibilities:

Jeff Gavlick limited populations coming to market. “There’s definitely a correlation between the cost of a drug and number of people that it is intended to treat; just basic supply and demand,” he adds. Another category that’s bright on Rx radar screens involves drugs to treat cancer, which Gavlick says has been the No. 1 claim category among his clients for many years running.

cites two FDA-approved gene therapies in the U.S., Luxturna and Zolgensma, as significant therapies and expects many similar drugs will be brought to market in the next few years. In addition, she says Roctavian, which will be approved by the FDA in 2022, would be a very costly to treat hemophilia A patients. “While the cost is significant,” she notes, “there’s also evidence that these drugs are beneficial, and in some instances, even curative.” The immunotherapy field, which includes the drug Kymriah, is extremely promising for cancer, and Kelly reports that “they’re being expanded from some of the broad cancers to more of the solid tumor areas… Everybody knows somebody who’s suffered with cancer. I have, myself. It’s just a matter of, how do we bring reasonable pricing to the equation.”

THE IMPORTANCE OF PLAN DOCUMENTS “It’s a major focus of the mission to a large extent hinges on the clarity of communication. The task force provider community to cure That identified plan documents as an area of critical importance “because it’s the central mechanism with which a plan sponsor can best control the cost and coverage of those cases, or at least medical and prescription drug services,” according to Gavlick, comparing them to help manage the disease an everyday product’s user manual. “Most claims administrators want for a longer life expectancy clear and concise guidance in the plan documents,” whose for the patient,” he observes. instructions help add clarity to an employer’s intent. “The clearer that plan “But many times, it’s at the document is, the more likely the plan sponsor is going to expense of the plan sponsor get the outcome they want.” of a self-funded program, and we are there to help JUNE 2021

7


Rx Cost Remedies Given the rising number of high-cost drugs and medical services, he believes employee benefit brokers should encourage employers to continuously update plan documents to help avoid very large claims that go unmanaged. This also would enable TPAs to better assist their clients. One of several Rx cost-containment strategies Gavlick recommends involves lowering the stop-loss deductible when patients are steered to the right intervention for a particular high-cost drug. Where the plan document comes into play, he says, is that it must be set up to ensure that Rx and other health care expenses are channeled to the most appropriate treatment options “in a cost-effective, safe and efficient manner.” Steve Kelly

DEFINING ROLES AND RESPONSIBILITIES The secret to success in taming Rx costs is largely predicated on the power of partnerships. And while each entity must stay in its own lane of expertise or authority, they will need to intersect at some point along the road to being good stewards of a self-insured health plan’s administration. “If everyone in the scope of what it takes to manage a self-funded plan does their part correctly, then I think you can really obtain successful results,” Diaz observes. The task force has been highlighting the importance of communication with all the parties, with Diaz describing the plan document as the center of all communication. She says articulating clear roles and responsibilities for all involved parties will help mitigate high-cost pharmaceutical charges both from a clinical perspective and financial impact on the plan. Key concepts include step therapy, validating whether the health plan member is tolerating a costly medication well and avoiding unnecessary waste of the medication.

Apart from prior-authorization strategies, which have long been implemented to manage Rx costs, Kelly cites patient assistance programs as an emerging method through which consultants match patients who cannot afford certain specialty drugs with financial subsidies from pharmaceutical companies. While it has been effective, he says “there are some differing opinions as to whether it’s appropriate.” Many of the leading disease states have formed associations to provide support and direction for families, he mentions, and oftentimes they work closely with

INNOVATIVE STOP LOSS AND ANCILLARY SOLUTIONS At BenefitMall, we know that employer groups benefit most from treating their health plan as an investment rather than an expense. Our team of self funded consultants can help you succeed by offering: • Reporting, Compliance Services and Plan Document Review • Billing and Premium Collection • Ancillary Products and Services

• Unbiased Expertise and Review • Initial Placement, Implementation and Renewal of Coverage • Claims Audit, Submission, Tracking, and Resolution Services

©2020 BenefitMall. All rights reserved.

www.benefitmall.com 8

THE SELF-INSURER

888.248.8952


WE ARE HERE FOR YOU Now, more than ever, it is important to do business with partners you can depend on. For more than 35 years, self-funded employers have trusted Sun Life to deliver flexible stop-loss options and seamless claim reimbursement. Helping you make the best decisions for your business is our business. Our team of dedicated experts is ready to support you with innovative solutions, tools, and resources to help you manage your self-funded plan every step of the way. Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life or click here to learn more!

STOP-LOSS

|

DISABILITY

|

ABSENCE

|

DENTAL / VISION

|

VOLUNTARY

|

LIFE

For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at www.sunlife.com. For more information about Sun Life products, visit www.sunlife.com/us. Stop-Loss policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, Stop-Loss policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2021 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503-n

SLPC 29427 02/21 (exp. 02/23)


What Employeers Really Want or are funded by the pharmaceutical industry and have relationships with hospitals

“We think that it behooves us to look as an industry into developing some dialogue with those entities,” Kelly says. “Perhaps that could lead to some more competitive pricing or case rates.” across the country.

Hear More from SIIA’s Drug Pricing Task Force SIIA’s upcoming National Conference will feature a live panel session where members of SIIA’s drug pricing task force will provide an update on the group’s findings and recommendations. Learn more at www. siiaconferences.org

Transparency, of course, is a chief objective for helping move the needle on opaque Rx pricing. Kelly believes progress is being made on understanding the shell game of drug rebates, pass-through agreements and spread-pricing. “We’re seeing more transparency and just pass-through PBMs where you can see what’s going on,” he says, adding that while rebates offer some relief, there are some better deals available. Self-insured employers often don’t devote enough time to review their PBM contracts or net plan cost, Diaz cautions, while sometimes they may pursue rebates at the expense of pursuing the best possible value for their Rx plan. While PBM rebates and passthroughs are a concern, Work says they’re not massive cost drivers. “It’s the fact that pharmaceutical companies are putting out these new drugs, and they’re $400,000, $500,000 a pop, and nobody knows and understands why they landed on that price, and more importantly, what the efficacy of it is,” he adds. By recognizing that drug pricing represents a common denominator for so many of its members, Diaz says SIIA has sought to provide a best-practices model that would be easily accessible to everyone; “that it could be, in many ways, a living document,” she explains. The bottom line is that more plans and advisers need to learn the nuts and bolts of Rx pricing. This will enable them to procure drugs in more efficient ways such as developing case rates with centers of excellence and building pathways with organizations that have experience with chronic disease states, Kelly says.

Protecting plans and patients across the U.S.

297

97.2%

50

On average,

aequum has

aequum has handled

aequum resolves

generated a savings

claims in all 50 states

claims within 297

of 97.2% off

days of placement

disputed charges for self-funded plans

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.

1111 Superior Avenue East Suite 2500 Cleveland, OH 44114

P 216-539-9370 www.aequumhealth.com

No Guarantee of Results – Outcomes depend upon many factors and no attorney can guarantee a particular outcome or similar positive result in any particular case.

10

THE SELF-INSURER


F E AT U R E

Dr Robert Lorenz

Spotlight Interview: Dr. Robert Lorenz, M.D., M.B.A., Executive Medical Director, Market and Network Services, Cleveland Clinic, Discusses Quality Healthcare, Services and Relationships in the Medical Travel and Tourism Industry

This interview was conducted by SIIA’s partner in the Connect from Anywhere (CFA) live Medical Travel seminars and was originally released as a special issue of their digital newsletter, prior to the Cleveland Clinic live seminar. A recording of the seminar is available to SIIA members at www.siiacanoe.org.

12

THE SELF-INSURER


Cleveland Clinic ABOUT CLEVELAND CLINIC Cleveland Clinic was at the forefront of modern medicine when its founders opened it as a multi-specialty group practice in 1921. In its first century, Cleveland Clinic has introduced many medical firsts, opened facilities around the world and is proud to be ranked among the top hospitals in the country. Now, 100 years later, the vision of the founders remains Cleveland Clinic’s mission: caring for life, researching for health, and educating those who serve. Visit https://my.clevelandclinic.org/.

ABOUT DR. ROBERT LORENZ, M.D., M.B.A., EXECUTIVE MEDICAL DIRECTOR, MARKET AND NETWORK SERVICES, CLEVELAND CLINIC

Robert Lorenz is the Executive Medical Director of Market and Network Services for the Cleveland Clinic. He is an active Head & Neck surgeon in Cleveland, Ohio, and was the former Chief Medical Officer of Cleveland Clinic Abu Dhabi. In his current role as Executive Medical Director of MNS, Dr. Lorenz participates in all aspects related to Cleveland Clinic’s contracting for specialty care, including innovative payment models, for both government and commercial payors. He coordinates the clinical aspects of revenue-related matters ($10.0bn), and works closely with Health Information Management to synchronize Cleveland Clinic physician involvement with payment risk-assumption. He has represented the Cleveland Clinic at the state level, serving on Governor John Kasich’s Advisory Council on Health Care Payment Innovation, and as the representative to Ohio State Medical Association’s Health System Physician Leadership Council. ______________________________________________________________________

MEDICAL TRAVEL & DIGITAL HEALTH NEWS (MTDH): PLEASE TELL US ABOUT YOUR BACKGROUND.

Robert Lorenz (RL): I am not originally from Ohio, but moved here with my family from the East Coast about 26 years ago. I am extremely proud to be a Cleveland Clinic physician. I practice cancer surgery half the time and spend the other half of my time engaged with my financing team to bring patients who could benefit from some of the services that we provide here from other areas. We are really a tertiary or quaternary organization. We are regarded as a “provider to providers” in some ways because of the robust services that are offered here. We are very proud of the outcomes Cleveland Clinic achieves and have a great team that includes people who take a lot of pride in practicing here.

MTDHN: Why do you think the Cleveland Clinic is such an outstanding example of health care quality and services? RL: Going back to that team concept, it is written into our DNA to “act as a unit.” That was the idea behind the founding of Cleveland Clinic. In Europe during World War I, when providers used to practice on their own, four physicians came together and said, “Isn't this great how we can augment each other's care when we work together as a team.” That team concept now prevails a century later. This year is Cleveland Clinic’s 100-year anniversary and our motto is still the same - to act as a unit. This allows us to put the patient in the center of what we do. We are only as good as the other team members around us. That is how we have such successful outcomes.

MTDHN: Are your patients local to the Cleveland area? RL: No, most of my patients are from either out of town or out of state, with a few out of the country. Similar to the many providers here, what I do is very subspecialized. Cleveland Clinic is known for triaging patients well so it’s common for patients to travel here from out of the region. Cleveland Clinic has a salary model, which is unique in healthcare. Having a salary model means our providers do not have any financial incentive to provide unnecessary treatments.

JUNE 2021 13


Cleveland Clinic That being said, the difference between U.S. healthcare and international healthcare is getting slimmer, so Cleveland Clinic also makes an effort to meet patients where they are. We have locations around the world including Cleveland Clinic Canada, Abu Dhabi and London, which will be opening up later this year, and we have partners throughout the world who we collaborate with on a clinical basis.

When I see a patient and I see that they have a nuance to their disease that might be better treated by one of my colleagues, I send them to my colleague and similarly, they send patients to me. That really benefits patients in the long run. That is why people come here from all over for specialty care.

MTDHN: Can you tell the readers about the relationships you have with your international partners throughout the world? RL: Again, Cleveland Clinic is 100 years old. There are original documents from the 1920s and 1930s that recorded, even at that time, patients were traveling internationally to receive care here.

Despite delays from the COVID-19 pandemic, Cleveland Clinic and Luye Medical are looking forward to the opening of the Shanghai Luye Lilan Hospital in 2025 (originally planned for 2024). The hospital is a Cleveland Clinic Connected hospital that will bring Cleveland Clinic's best practices to China in Shanghai's New Hongqiao International Medical Center.  Our Florida location has a very robust international office and sees patients from all over Central and South America.

Our international footprint really expanded when we were the only provider in the world doing some unique things. For example, at one point we were the only facility in the world that was performing coronary bypass surgeries.

MTDHN: Can you talk about some of Cleveland Clinic’s service lines?

Scale that to many different diseases and procedures and indeed, we have a lot of people who come to us from around the world for care.

RL: Our main campus is organized around the patient.

14

THE SELF-INSURER


Accident & Health Insurance

We’ll focus on risk, so you can take care of

your business

Get the help you need to self-fund your healthcare and grow your business. Self-insuring your healthcare benefits can be a big step for your company – and a complicated one. But with a medical stop loss solution from QBE, our experts will help you determine the level of risk protection to meet your financial needs. Discover a range of products to help you protect your assets: • Medical Stop Loss • Medical Stop Loss Captive • Special Risk Accident • Organ Transplant Together, we’ll create a solution that fits your needs – so no matter what the future holds, you can be sure that QBE is with you.

Premiums4Good When you choose QBE, you choose to give back – with a portion of all customer premiums committed to investments with social and environmental objectives.

For more information, visit us at qbe.com/us

Alternative Markets

Crop

Specialty & Commercial

QBE and the links logo are registered service marks of QBE Insurance Group Limited. ©2021 QBE Holdings, Inc. This literature is descriptive only. Actual coverage is subject to the terms, conditions, limitations and exclusions of the policy as issued.


Cleveland Clinic A traditional healthcare provider has a cardiology department and if they are served by surgery, they go to a separate cardiac surgery department. That is the traditional model. Our model is different. The Cleveland Clinic model is that if you have issues with your heart, for example, and you come to the Heart, Vascular & Thoracic Institute, we will figure out whether you will be best treated with intervention, medication or lifestyle modification. This is a unique model called the Institute model. Toby Cosgrove, a former Cleveland Clinic CEO, launched us around centering ourselves around the patients’ problems. That being said, we currently have 21 Institutes including Heart, Vascular & Thoracic and Digestive Disease & Surgery. I am in the Head and Neck Institute where we combine otolaryngology, dentistry and maxillofacial surgery. The Neurological Institute combines neurology and psychiatry. That is how we are organized, around organ systems and disease processes, and less around the traditional healthcare entities. The other Institutes can be found here.

16

THE SELF-INSURER

MTDHN: Tell us about the technology services the Cleveland Clinic offers. Are there telehealth or telemedicine programs? RL: Yes, we launched into telehealth in a big way long before COVID-19. We use telehealth for primary care, which we have a robust program for, to serve patients who see us as their primary care. Even local patients in Cleveland and throughout the rest of Ohio sometimes use telehealth. We have a joint venture with Amwell called The Clinic by the Cleveland Clinic which we use our telehealth platform to provide second opinions. Second opinions are great because they can introduce new ideas and groundbreaking technologies into the patient's care plan that the patient may not have been aware of. Getting an external, objective second opinion can either validate or introduce a new idea. They are very valuable. We can do that for providers or patients through the joint venture.

MTDHN: Can you address the Cleveland Clinic's positioning worldwide? What relationships does it have with employers and payers? RL: A lot of providers out there delve into the payer market and they launch their own health plans. We decided we should stick to our knitting and continue being an outstanding care provider.


Cleveland Clinic We do not have our own plan in the market, but we do have joint ventures with plans like Oscar, Humana and others. In general, we make sure that our value proposition is being a great provider. As far as our international relationships, we have partners in Europe and the Middle East. Something unique we do as an organization based out of the United States with entities in other countries, is to share access to medical records between our organizations. That enables a patient living in or visiting Europe, who had their previous care in the U.S., to have their records accessible to the providers at the Cleveland Clinic locations in Europe. Cleveland Clinic has a great value proposition with sharing those records in terms of providers with an international workforce. That allows us to take care of the patient anywhere, whether it is virtually or in one of our international offices.

MTDHN: Can you tell the readers about the Cleveland Clinic’s experience contacting directly with large employers? RL: When you have a value proposition like this in Ohio, there are a lot of people who want to take advantage of it. When you look at the outcomes that our providers achieve, they are producing market leading outcomes with significantly decreased mortality rates, increased back-to-work rates and decreased pain. Cleveland Clinic has outstanding Net Promoter Scores.

For large employers, a heart condition like a leaky heart, for example, is relatively common. That prompts employers to say, “, I've got a sizable workforce. How many of my employees have a heart condition, neurologic condition or spine condition? How can I get my employees who are most challenged with health concerns, access to the Center of Excellence?” Our Centers of Excellence have white glove concierge service for people who are coming to midtown Ohio, but we also engage employers who are not local with virtual care or optimization of their medical problem. Then, if they need face to face meetings, they can come to Ohio. A lot of our care nowadays is done virtually because providers’ expertise can be easily delivered to patients wherever they are. Healthcare is shifting to have less geographic boundaries. It is much more about triaging the correct provider to the right patient at the right time. I think in about 5-10 years down the road, healthcare is going to be about the value providers can demonstrate to employers and how providers can package care to the employer for the right employee. Centers of Excellence are a great example of that because they offer expertise with a collaborative approach, centered around disease processes and the patients’ problems. MTDHN: Is there anything else you would like to share with the readers? RL: It is in the Cleveland Clinic’s DNA to take care of patients locally and from outside our region. I think we will find that those who pay the bills and those who are responsible for the cost of medicine, will see that value comes through higher quality. Doing things right the first time, not doing unnecessary testing or non-value-added services and making sure that patients do not get re-admitted will save money. Similarly, making sure that our care and outcomes are durable, and patients do not have recurrences or need revisions is very important. Cleveland Clinic is very centered around durable outcomes. We were one of the first providers to publish our outcomes, in an effort to be transparent. They are publicly available online. Our concept of delivering value is focused on getting employees back to the workforce and in a pain-free, healthy state. The best thing we can do for patients is help them return to a state of feeling good so they can develop their careers, be participating members of society and spend time with their families. Our model is centered around focusing on individual patients and employees and thinking about what matters to them the most, which is returning to health. That is what our model is geared around, and I think that is why we have been so successful.

JUNE 2021

17


A New Approach to Conferencing Here. There. Everywhere. Our most flexible event ever, SIIA's 2021 National Conference gives you access to presentations, online exhibits and networking forums from virtually anywhere. PLUS, if you're ready to travel, then come on down to Austin and join us for some good old-fashioned in-person networking!

Long Time, No See! For many, it's time to reconnect...and to help things along, we're introducing The Blue Eagle Networking Lounge. It's the perfect spot for a morning meeting over coffee, a game of pool at lunch or a quick cocktail before dinner.

Shop Online Visit the virtual exhibit hall and engage directly with hundreds of companies offering valuable self-insurance and captive insurance solutions.

Let's Learn Together Keynote Speaker

Mike Walsh | Futurist The Way Forward | New Rules for the New World The health care and insurance industries will continue to evolve in a post-COVID world.

This year's educational program features many younger industry experts. We can't wait to share their fresh perspectives and energy!

"Don't look back...you're not going that way" - Mary Engelbreit 2021 Self-Insurance Institure of America


SIIA ANNOUNCES ITS 2021 NATIONAL CONFERENCE

T T

he Self-insurance Institute of America, Inc. (SIIA) has announced the program and opened registration for its 2021 National Conference. This year’s theme is “The Way Forward.” The world’s largest self-insurance event is back with an entirely fresh approach to conferencing, which will deliver the best of virtual and in-person formats to create an opportunity to allow everyone to participate in whatever way that works best for them and their organizations. The in-person component of the conference will take place October 3-5, 2021 at the JW Marriott Hotel in Austin, TX. SIIA will be transforming more than 50,000 square feet of hotel ballroom space into a comfortable and stylish lounge area, creating the perfect environment for meetings and networking from beginning to end. This will be supplemented by evening receptions, other food & beverage functions, and table-top exhibit viewing. All of the high-quality educational content will be delivered via a sophisticated virtual platform, with a combination of live and pre-recorded sessions scheduled during the conference. This content can viewed by those who join us in Austin, and from anywhere for those who choose to participate virtually. Additional virtual features include two networking luncheons, an exhibit hall, private messaging opportunities with other attendees, and lively chat rooms. For planning to attend in person, SIIA has reserved a block of discounted sleeping rooms at the host hotel but we expect this block to be sold out well in advance of the conference, so it is highly encouraged to reserve your room at the earliest opportunity. Sign up before June 30 and take advantage of early bird registration fees. For companies looking to promote their corporate brands within the self-insurance/ captive insurance marketplace, there is simply no better event. This is particularly true this year as you have the potential to reach both a large in-person and virtual audience. Contact Justin Miller at jmiller@siia.org for immediate assistance. Complete event information can be accessed at www.siiaconferences.org or by calling 800/851-7789. SIIA looks forward to seeing you in Austin, or for you joining us virtually from wherever you are.

JUNE 2021

19


DEVELOPING ISSUES CHALLENGING THE CAPTIVE INDUSTRY

C

Written By Karrie Hyatt

C

aptives have been hit with a number of challenges so far this year. Even while captive numbers are growing as a result of the hard market and the pandemic, obstacles—from state legislation to continued IRS actions—have continually been thrown in their way. There is a silver lining to the clouds that have been shading the industry that comes from the U.S. Supreme Court decision in favor of CIC Services Inc. in its suit against the IRS, which was announced in mid-May.

WASHINGTON STATE LEGISLATION

Since 2018, the Washington state Office of the Insurance Commissioner has been investigating captive insurance companies operating in the state. The culmination of this investigation has resulted in the passing of legislation by the state that requires captives to pay premium tax on the risk insured for their parent company.

20

THE SELF-INSURER


Insurance Commissioner Mike Kreidler first made waves in May 2018 when he issued a cease-anddesist order to Cypress Insurance Company, a pure captive owned by Microsoft Corporation, requiring that the captive stop selling insurance to its parent company and pay more than two million in back taxes and penalties.

Cypress Insurance is domiciled in Arizona and had been insuring its parent company since 2008 without using a fronting carrier. By August 2018, the case had been settled out of court with reduced fines for the insurer. After the settlement, Commissioner Kreidler announced via a press release that the state would pursue other captive insurance companies insuring risk within the state.

The commissioner kept his promise and has investigated and fined other captives, including Costco’s captive, NW Re Limited. Washington is one of just a dozen states that does not have captive law and was one of the few states in the U.S. that did not have direct procurement or self-procurement tax requirements. Direct procurement taxes are levied

by states when a company purchases insurance from an insurer not licensed or registered in the state.

Last August, Commissioner Kreidler surveyed around 5,000 businesses in the state to determine how many businesses insure through captive insurance. This was done in an effort to determine how much risk in the state captives were covering. In a report of the survey, compiled by actuarial firm Milliman, it was estimated that in 2019 captives collected $300 million in direct written premiums.

In February of this year, Bill 5315 was introduced in the state senate. The bill requires captive insurers to pay a 2% procurement tax on premiums. Captives would also have to register with the state and pay an initial $2,500 fee, as well as an annual renewal fee of up to $2,500.

Captives insuring public institutions of higher education are exempt from the law. Captives that have been insuring risk in the state since January 1, 2011 will owe back taxes on any premiums for which they have not previously paid taxes, but will not be subject to penalties and fees for non-payment.

JUNE 2021

21


The legislation was approved by the state senate in March and by the house of representatives in April, then landed on Governor Jay Inslee’s desk. He signed the bill into law on May 12th.

Criticized as “poorly drafted” by Vermont Captive Insurance Company president Rich Smith, the legislation will add a layer of regulation to captives insuring their parent companies. The concern among captive professionals is that other states without direct procurement tax for captives will see Washington’s efforts as a revenue generator and will follow the state’s lead in profiting off captive insurance companies, making operating a captive more expensive.

AND THE IRS

Last year, amid the pandemic, the IRS continued to pursue micro-captives—their term for ERCs that take the 831(b) tax election. With actions in March, July, and October, and twelve investigative teams launched to focus solely on micro-captives, the Service continued its charge against captives they see as abusive.

CAYLOR DECISION

The captive industry took another blow in March when the U.S. Tax Court decision was handed down in Caylor Land & Development v. Commissioner. This was the fourth case in which the Tax Court decided in favor of the IRS involving ERCs that elect to take the 831(b) tax option.

Judge Holmes, who also decided the Avrahami case, cited all three previously decided cases (Avrahami, Reserve Mechanical, and Syzygy) in his decision, finding that Caylor’s use of their captive, Consolidated Inc., did not constitute insurance. Unlike the three previous cases, Caylor did not involve a question of risk distribution, but brother-sister insurance arrangement.

The decision in this case has been long in coming with the original hearing in 2017 and was not a huge surprise for the captive industry given the previous three decisions. The biggest surprise was that Judge Holmes ordered penalties to be paid. In the previous cases, the companies involved were charged with paying back taxes but were shielded against penalty fees by section 6664(c) that allows for a good faith defense.

One point about all four of these cases is that the period of operation in question for each is prior to 2014, and for Avrahami as far back as 2009. The IRS seems to be focusing on ERCs from when small and medium-sized captives first really began forming and opting for the 831(b) tax exemption in the late part of the 2000s.

Caylor was the last of the Tax Court decisions that the captive industry had been waiting for. Although, in the case of Reserve Mechanical Corp. v. Commissioner, while the Tax Court found in favor of the IRS, the decision has been appealed, so the final outcome in still undecided.

22

THE SELF-INSURER

This year is no different. In early April, the IRS released a letter urging “abusive micro-captive insurance arrangements to exit these transactions as soon as possible.” The statement came a month after the Caylor decision was handed down and capitalized on the Service’s fourth court win.

As has been the case for going on eight years, the IRS admonishes abusive micro-captives while offering zero guidance on what a properly structured micro-captive looks like. At this point, it seems that by not describing a “good” captive the IRS is assuming all microcaptives are abusive.

This is the stance that SIIA took in an April 16 statement responding to the IRS’s letter, “While the IRS continues activities related to captive insurance, it must also move towards recognizing what an appropriate structure is, and issue appropriate guidance to that purpose.” SIIA supports curbing abuses within the industry and supports legitimate efforts to weed out abusive transactions. However, the vast majority of captive owners and professionals are using micro-captives responsibly.


According to the IRS’s narrative, there are no ERCs that are using the 831(b) tax option for legitimate business purposes. Yet, as last year proved, captives are incredibly important to help small and medium-sized businesses on a day-to-day basis, and especially in times of upheaval.

SIIA’s statement ends with “While the IRS may remain focused on certain captive structures, SIIA strongly believes that it must do so in a responsible and fair manner. As American business continues to navigate through COVID disruptions, captive insurance companies remain committed to providing a needed and legitimate risk management tool for these businesses to grow and thrive.”

In contrast, as if to emphasize their commitment to pursue ERCs, on April 19, the IRS announced the establishment of the Office of Promoter Investigations (OPI). According to the statement released by the Service, the office will expand the efforts of the Promoter Investigations Coordinator, a position established last summer.

The OPI will focus of promoters of abusive tax avoidance transactions which covers a variety of tax-dodging schemes. However, Commissioner Chuck Rettig made no pretense that micro-captives were not one of the main focuses of the new office. “This office will coordinate efforts across multiple business divisions to address abusive syndicated conservation easements and abusive micro-captive insurance arrangements, as well as other transactions,” he was quoted as saying in the IRS’s announcement.

While this office may fill a need in the IRS’s administrative structure, the captive industry is still waiting for guidance relating to abusive captive practices as authorized by Congress in the PATH Act of 2015. There is no indication that the OPI has any directive regarding establishing guidance for captive owners and professionals. The IRS continues its laser focus on ERCs hindering the operation of well-structured captives instead of helping by offering direction. Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.

Better manage your specialty drug spend, through powerful clinical management combined with real-time oversight. Every organization struggles to manage its Specialty Drug spend. ELMCRx Solutions understands the complexity of specialty drug management. By combining powerful clinical management with real-time oversight to control costs and prevent unnecessary payments, our unbiased program helps deliver the best outcome for the plan sponsor and the member. We partner with employers, health care coalitions, health plans, insurance captives, TPAs and Taft-Hartley Trusts. Cost Containment Solutions and superior clinical outcomes are achievable. ELMCRx Solutions is the partner to help you achieve them.

CONTACT US TODAY

John Adler jadler@elmcgroup.com | 262 707.1076 Mary Ann Carlisle mcarlisle@elmcgroup.com | 484 433.1412 elmcgroup.com

24

THE SELF-INSURER

An ELMC Risk Solutions Company


300 YEARS OF EXPERIENCE Put simply: AccuRisk’s combined 300 years of experience amounts to some serious intellectual capital translating to better solutions and higher profits for our partners. With our diverse backgrounds and extensive understanding of the industry, we continually stay ahead of the competition, trends and problems. We create solutions before they are even needed in: • Medical Stop-Loss • Occupational Accident • Supplemental Coverage • And More….

So what’s YOUR problem? AccuRisk will use our experience to help you solve it. info@accurisksolutions.com accurisksolutions.com (312) 857-9100


PENSION RULING LIMITS HEALTH PLAN MISMANAGEMENT CASES

I

Written By Brady Bizarro, Esq.

I

n the complex world of ERISA litigation, court rulings can often impact both retirement and health and welfare benefit plans. When a crossover occurs in a case primarily involving retirement plans, the impact on health and welfare plans is typically limited.

Every so often, though, a case centers around a threshold question which impacts every federal case, and as such, the ruling has significant consequences for all employee benefits cases.

Last summer, the Supreme Court of the United States decided Thole v. U.S. Bank N.A., a case principally about pension plans.1 The 5-4 ruling was considered extremely consequential in this area because it limited beneficiaries’ right to sue plan fiduciaries.

Now, attorneys representing health plan fiduciaries are finding success in utilizing the Court’s ruling in Thole to dismiss cases brought against them.

26

THE SELF-INSURER


The Thole case involved one of the most fundamental legal doctrines in America law: the standing requirement. Standing is the determination of whether a specific person is the proper party to bring a matter to a court for adjudication.

To establish constitutional standing, a plaintiff must prove (1) that she suffered an injury in fact that is concrete, particularized, and actual or imminent, (2) that the injury was caused by the defendant, and (3) that the injury would likely be redressed by the requested judicial relief.2

Here, the plaintiffs, Thole and Smith, were two retired employees who participated in U.S. Bank’s retirement plan. They filed a class-action suit against the plan fiduciaries, alleging that they mismanaged more than $748 million, causing them harm. The Court ruled that because the plan participants had suffered no monetary injury, they lacked standing to sue the plan fiduciaries.

To understand why this case is having a major effect on health plan litigation, it is essential to dig into the facts, the Court’s majority opinion, and its lengthy dissent authored by Justice Sonia Sotomayor. The plaintiffs in this case were part of a defined-benefit plan, not a definedcontribution plan.

In defined-benefit plans, retirees receive a fixed payment each month, and those payments do not change with the value of the plan or because of plan fiduciaries’ good or bad investment decisions.

Compare that to a defined-contribution plan, most commonly a 401(k) plan, in which benefits are usually tied to the value of their accounts, and those benefits can fluctuate depending on plan fiduciaries’ investment decisions.

Thole and Smith, as pensioners, receive $2,198.38 and $42.26 per month, respectively, despite the plan’s value at any given moment or any of the investment decisions made by the plan fiduciaries. They have received all of the money due to them and are legally and contractually entitled to receive those amounts for the rest of their lives.

JUNE 2021

27


While the plaintiffs did not sustain a monetary injury, they brought suit against the plan fiduciaries under ERISA, claiming that the defendants violated ERISA’s duties of loyalty and prudence by poorly investing plan assets some ten years ago, to the tune of a $748 million loss. They asked the Court to force the fiduciaries to repay the losses to the plan, to replace the plan fiduciaries, and to award them $31 million in attorney’s fees.

The district court in Minnesota found that the plaintiffs had sufficient standing to proceed with the case, and after that determination, U.S. Bank made a substantial contribution to the pension plan, bringing it above the statutory minimum. The district court ultimately dismissed the case, and on appeal, the

U.S. Court of Appeals for the Eighth Circuit found that the plaintiffs lacked statutory standing.

Justice Brett Kavanaugh authored the Supreme Court’s majority opinion, joined by the Court’s other conservative justices. He noted that the pensioners had thus far received all of the money due to them and that the outcome of this suit would have no impact on the plaintiffs’ future monthly benefit benefits.

If they lost the case, they would still receive the exact same monthly payment. If they won the case, they would not receive any additional benefit payments. The majority went on to dismiss four alternative arguments advanced by the plaintiffs, concluding that they lacked a sufficient stake in the case to have standing to sue.

First, the plaintiffs argued that a plan fiduciary’s breach of a trust-law duty of prudence or duty of loyalty itself causes harm, even if the plan participants have not and will not suffer any monetary losses.

From day one, StarLine’s differentiator has always been its people. Of course, we have decades of experience, but we are also genuine, capable, and collaborative. Our team always goes above and beyond to create and sustain solutions to match today’s constantly evolving needs. There is no part of our process that is not underscored by a dedicated group powered to propel you forward. Call us today at (508) 809-3179 or visit starlinegroup.com and linkedin.com/company/star-line-group Stay safe and stay well.

STOP LOSS | CAPTIVE | PAYOR | PROVIDER | ACO | GROUP ACCIDENT

28

THE SELF-INSURER


The Court disagreed, noting that this argument would be proper if the plan at issue were a defined-contribution plan or a trust. In a defined-benefit plan, the Court does not recognize a plan participant’s equitable or property interest in the plan. Then, the Court determined that the plaintiffs did not have standing as representatives of the plan itself because they did not suffer an injury in fact.

Justice Sotomayor wrote a lengthy dissent, joined by Justices Ginsburg, Breyer, and Kagan. For the dissent, there is no meaningful difference in the rights afforded to participants of defined-benefit plans from those of defined-contribution plans or trusts.

Third, the plaintiffs argued that language in ERISA itself grants plan participants a statutory right to sue for breach of fiduciary duty and other equitable relief. In response, the majority noted that a statutory right to sue does not itself satisfy the constitutional standing requirement.

For example, the Supreme Court has long recognized that a breach of fiduciary duty claim exists regardless of the beneficiary’s personal gain or loss. It is for this reason, the dissent observes, that the majority declares that this case has no bearing on those alleging failure to provide plan information (which would support standing).

Finally, the plaintiffs asserted that if beneficiaries are unable to bring fiduciary breach claims against plan fiduciaries, no one will meaningfully regulate plan fiduciaries. Here, the Court noted that employers have strong incentives to avoid fiduciary misconduct because they are on the hook for plan shortfalls.

ERISA authorizes the Department of Labor (“DOL”) to enforce fiduciary obligations, and the Court explained that since the federal government is required by law to pay vested pension benefits of retirees, the DOL has a strong incentive to police plan fiduciaries. Further, certain claims of fiduciary misconduct can be bought directly against individual plan fiduciaries (for example, if using plan assets for personal gain). Justice Kavanaugh sums up oversight of ERISA plan fiduciaries as a “regulatory phalanx.”3

Without affording plan participants in these cases an equitable interest in the plan, no one would hold that title, leaving about 35 million people with defined-benefit plans vulnerable to fiduciary misconduct in the eyes of the dissent. Justice Sotomayor also found the majority’s argument that a financial injury is necessary to establish standing exceedingly unpersuasive.

The majority did not persuade the dissenting justices that a beneficiary’s noneconomic right to loyalty and prudence from fiduciaries is meaningfully different.

The dissent also presents two arguments for standing based in contract law. First, they observe that the Plan Document itself confers upon the beneficiaries an equitable stake in the financial integrity of the plan.

Second, they cite to the majority’s claim that the plaintiffs have a contractual right to receive monthly payments for life and note that a breach of contract always creates a right of action, even when no financial harm was caused.

Essentially, the dissent recognizes an equitable interest based in trust law for defined-benefit plans while the majority views beneficiaries’ rights under these arrangements as largely contractual.

Since the Thole decision, over one hundred cases have cited to its holding. Out of those, at least three cases involved health and welfare benefit plans and claims of health plan mismanagement. They were all dismissed by courts for lack of standing.

At first glance, this should seem unusual because unlike pension plans, self-funded health plans are not defined-benefit plans. The Court’s ruling in Thole did not

JUNE 2021

29


contemplate health and welfare benefit plans. If anything, self-funded health plans are most like defined-contribution plans since the “benefit” received is not defined and the contribution, the amount contributed by a plan participant to the plan, is typically defined.

Nevertheless, the strategy being utilized by attorneys representing self-funded plans is to analogize the facts of their cases with Thole.

In particular, they assert that the alleged fiduciary misconduct never had or will have a material impact on the benefits due to plan participants. In De Fuente v. Preferred Home Care of N.Y. LLC, the plaintiffs were home health aides enrolled in a self-funded health plan.4

The plan was part of a captive arrangement in which the employer paid premiums to the captive insurer, which then used the premium to establish a reserve to pay covered medical claims. The plaintiffs alleged the employer breached its fiduciary duties and engaged in prohibited transactions under ERISA by receiving profits and excess premiums from the captive insurer.

The district court found that the plaintiffs, like those in Thole, had received all of the benefits to which they were entitled and winning or losing would not increase their health benefits. As such, the district court found that the plaintiffs lacked standing to sue.

30

THE SELF-INSURER

In Crosby v. Cal. Physicians’ Serv., the plaintiffs alleged that their health plan improperly considered age and therapy history in medical necessity determinations for children with autism.

The district court cited Thole, noting that the plaintiffs had received all of the benefits due to them, and that the plaintiffs must show they have been injured beyond their need to pursue administrative appeals. In the district court’s view, they did not, and the case was dismissed for lack of standing.5

Finally, in Bryant v. Wal-Mart Stores, Inc., the plaintiff brought suit against Wal-Mart’s health plan for alleged failure to provide timely COBRA notices. The district court, however, found that the plaintiff was not injured by a lapse in coverage, and cited to Thole when it dismissed for lack of standing.6

Taken together, these cases, with their reliance on the holding in Thole, reveal that the Supreme Court has paved the way to limit suits against health plan fiduciaries alleging mismanagement of plan assets.

It will now be much more difficult for plan participants to satisfy the constitutional standing requirement in ERISA cases where they are alleging breach of ERISA’s duties of loyalty and prudence by poorly investing or utilizing plan assets.

The Court made clear that in such cases, the plaintiff would have to show that they received fewer benefits due to them, or will receive fewer benefits due to them, as a result of the alleged fiduciary breach.

One unanswered question in the Thole case involves extreme situations. The majority left open the question of whether a plaintiff would have standing to sue when “the mismanagement of the plan was so egregious that it substantially increased the risk that the plan and the employer would fail and be unable to pay the participants’ future pension benefits.”7

In today’s economy, given the volatility of the post-pandemic market and risky investment opportunities such as cryptocurrency, I would caution plan fiduciaries to continue to handle plan assets with the skill and prudence which is typical in our industry.


Brady Bizarro, Esq. Director, Legal Compliance & Regulatory Affairs

Brady joined The Phia Group as a healthcare attorney in early 2016. As the Director of Legal Compliance & Regulatory Affairs, he specializes in regulatory, transactional, and compliance matters related to healthcare and employee benefits law. He provides general consulting services to clients, including employers, third-party administrators, brokers, and vendors associated with health benefit plans on matters related to the health insurance industry, including ERISA, ACA, and HIPAA compliance.

He also performs contract review and due diligence on healthcare transactions and assists with dispute resolution efforts between the various players in the healthcare industry in an effort to protect plan members and plan sponsors. Brady has previously spoken at numerous industry conferences, including those held by the Self-Insurance Institute of America (“SIIA”) and the Health Care Administrator’s Association (“HCAA”). He served as chairman of SIIA’s Future Leaders Committee in 2020 and is a regular contributor to The Self-Insurer, the world’s leading alternative risk transfer journal.

Attorney Bizarro earned his law degree from Boston University School of Law, concentrating in health law. During law school, Brady served as an editor for BU Law’s International Law Journal, participated in the Edward C. Stone Moot Court Competition, completed a legal internship in the U.S. House of Representatives, and wrote for the National Security Law Brief. He also worked as a summer associate at Greene LLP, a complex civil litigation firm in Boston that specializes in healthcare fraud cases, and as a Rule 3:03 attorney with Greater Boston Legal Services, where he represented indigent defendants in employment and discrimination cases in state court.

Prior to law school, he worked as a mediator for the Massachusetts Attorney General’s Office and for the National Defense University in Washington, D.C. Brady graduated magna cum laude in 2010 from Boston University, where he was the recipient of the Herbert and Mary Greig Scholarship in American History.

32

THE SELF-INSURER

References: 1 Thole v. U.S. Bank N.A., 140 S. Ct. 1615 (2020). 2 Lujan v. Defenders of Wildlife, 504 U. S. 555, 560-561 (1992). 3 Thole, at 1621. 4 De Fuente v. Preferred Home Care of N.Y. LLC, 2020 U.S. Dist. LEXIS 187681, at *1 (E.D.N.Y. Oct. 9, 2020). 5 Crosby v. Cal. Physicians’ Serv., 2020 U.S. Dist. LEXIS 210654, at *1 (C.D. Cal. Nov. 2, 2020) 6 Bryant v. Wal-Mart Stores, Inc., 2020 U.S. Dist. LEXIS 125266, at *10 (S.D. Fla. July 15, 2020) 7 Thole, at 1621-1622.


+ =

Comprehensive and complete bill review solutions Kozani Health has joined the Vālenz® ecosystem of data-driven solutions as Vālenz ProteKHt™ to provide you with transparent cost savings at each step in the life cycle of a claim. With clear, defensible, transparent and plan-specific reviews, Vālenz ProteKHt™ ensures appropriate and accurate charges are accounted for on every line of every claim. Vālenz ProteKHt™ delivers savings of 10-30 percent above the PPO allowable with a signed contract, agreed upon and authorized by the provider. Our enhanced bill review solutions join the Vālenz ecosystem in strengthening your ability to realize every opportunity to balance cost, quality and utilization.

Get started on the path to smarter, better, faster healthcare with Valenz ProteKHt™ today. Call 904-414-3213 or visit valenzproteKHt.com.

valenzproteKHt.com Proud to be a Diamond Member


ENDEAVORS

SIIA ENDEAVORS

JUNE CONNECT FROM ANYWHERE (CFA) EVENTS

ADVOCACY IN ACTION – JUNE 8, 2021

With a new Administration and new Congress in Washington, DC, 2021 promises to be a very active year with regard to legislative/regulatory developments affecting the companies involved in the self-insurance/captive insurance marketplace. To keep members informed about what they need to know, SIIA’s government relations team will be holding a monthly webinar series from January through June.

34

THE SELF-INSURER


Scalable Solutions for Self-Funded Employers We’re a leading third party administrator for self-funded employers of all sizes, in all industries. Driven by the unique needs of our employers and brokers, our proprietary technology systems enable us to administer cost-effective plan designs that match the needs of your organization. Full Suite of Solutions

In addition to claims and benefits administration, we offer pharmacy benefit management, health management and wellness programs, stop-loss insurance, and print and payment solutions. Seamless Integration

We offer a broader range of services compared with other TPAs and administer solutions that seamlessly integrate with your vendors. See What Pinnacle Can Do For You

866.930.PCMI Quotes@pinnacleTPA.com www.PinnacleTPA.com


ENDEAVORS WHAT SELF-FUNDED EMPLOYERS REALLY WANT

MENTOR CONNECTION FORUM

– JUNE 15, 2021, 2:00 - 3:00 PM EDT

– JUNE 16-17, 2021

A series of listening sessions conducted over a two-year period with members of employer coalitions in four U.S. cities provided some amazing insights into what selffunded employers expect from their healthcare partners. The participating employers also shared their frustrations over the lack of collaboration in finding solutions to today’s health care crisis. This webinar featuring representatives from those listening sessions will recap some of the findings, including just how employers feel about:

This interactive event has been designed to connect younger SIIA members (under age 40) with several of the most successful senior self-insurance/captive insurance industry executives in a “speed-mentoring” format. Attendees will have unique access to those who can provide practical career advancement advice, including tips on how they can be more valuable to their employers.

• Healthcare system consolidation

• Provider network design

• Alternative payment models

• Pricing transparency

• Lack of quality data

• Gaps in the patient experience and access

• Integrating primary and behavioral healthcare

The sessions were conducted as part of a joint project of the National Alliance of Healthcare Purchaser Coalitions and the Council of Accountable Physician Practices, a coalition of the nation’s leading medical groups and health systems. Coalitions based in Dallas, TX; Northeastern PA; Chicago, IL; Seattle, WA; and Charlotte, NC participated in the sessions. Moderator: Joanne Wojcik Content Developer Self-Insurance Institute of America, Inc. (SIIA) Speakers: Michael Thompson President & CEO National Alliance of Healthcare Purchaser Coalitions Norman Chenven, M.D. Founding CEO Austin Regional Clinic and Vice-Chair, CAPP Cheryl Larson President & CEO Midwest Business Group on Health Cost: No charge for SIIA Members

36

THE SELF-INSURER

The Zoom format will also encourage interaction among attendees, which is important in helping them develop the professional networks necessary to further accelerate their success in the self-insurance/captive insurance industry – networks the mentors have spent many years developing for themselves.

Due to logistical restrictions of the format, attendance will be limited to 100 participants, so please register early if you would like to participate.

MEET THE MENTORS SIIA is pleased to announce the following list of mentors who have confirmed their participation in this year’s Mentor Connection Forum. As you will see, they represent all segments of the selfinsurance marketplace (group health, captives & workers’ compensation) and each one of them have been very successful in their respective careers as well as being highly involved with


ENDEAVORS SIIA in various capacities. Additional mentors may be announced closer to the date, so please check back periodically to see the latest line-up.

The Bend the Health Care Trend book(s) explore how healthcare consumers can counteract the damaging effect of the US health care system with misaligned incentives, opaque pricing schemes, and unnecessary complexity. It highlights consumer-driven health care and wellness plans and how employers can empower employees to control insurance costs.

Inspire to Act and Inspire to Act for Kids are collections of stories that help others to embrace the power of kindness and live an attitude of gratitude.

Jennifer Borislow Jennifer Borislow Principal Borislow Insurance Jennifer A. Borislow is the founder and Chief Executive Officer of Borislow Insurance, a leading provider of innovative health and wellbeing benefits solutions. Borislow Insurance serves more than 300 businesses throughout New England with an expertise in transforming workplace culture by creating a community of consumerism and empowering employees to make informed health care choices.

She also authored If I Had Only Known with Melissa Marrama and Michaela Scott. If I Had Only Known are checklists and guidance before and after a loved one dies. This guidebook offers step-by-step instructions on how your family can prepare for – and avoid – the most common missteps and challenges related to the death of a loved one.

She is an industry leader and active participant on several insurance company advisory boards. Jennifer currently serves on the Board of Trustees at Northern Essex Community College as Chairwoman, Merrimack Valley YMCA as well as Kimball Union Academy in Meriden, NH. She is a frequent keynote speaker at many national and international events. Her commitment to community involvement is highlighted by her passion to make a difference in the lives of others.

Jennifer is a graduate of Dickinson College. She is married to Michael and they have two daughters, Jessica and Lauren and son-in-law Joshua Dollinger.

Jennifer is past president of The Million Dollar Round Table, a global, independent association of more than 62,000 of the world's leading life insurance and financial services professionals from more than 500 companies in 69 nations.

Andrew Cavenagh CEO Pareto Health, Inc.

She is the co-author of four books, Bend the Healthcare Trend 1 and 2, Inspire to Act and Inspire to Act for Kids with her business partner, Mark S. Gaunya.

Andrew didn’t invent the healthcare benefit captive, but he and Andrew Clayton were among the first to understand the incredible potential of self-insurance and captives to transform the employee benefits market.

Andrew Cavenagh As CEO and founder of ParetoHealth, Andrew is leading the charge to dismantle outdated health insurance approaches and challenging organizations to build new ways to bring affordable healthcare to their employees.

JUNE 2021

37


ENDEAVORS Prior to forming ParetoHealth, Andrew help found Garnet Captive Services, LLC and Elevate Insurance Services, LLC. He retains a seat on the boards of both companies.

Andrew started his career in commercial banking and worked at several publicly traded insurance companies. He has served on committees and boards of industry groups such as the SelfInsurance Institute of America. Andrew is a graduate from Swathmore College.

Loss & Health – the fastest growing and most profitable division of Sun Life’s U.S. business and the largest independent stop-loss insurance provider in the country.

As head of Stop-Loss & Health, Jen oversees all aspects of the Sun Life’s StopLoss business, including product development and strategy, data analytics, product pricing, underwriting, distribution and claims. She brings both clinical and business management expertise to risk and cost-management strategies for Sun Life's selffunded employer clients.

Under her leadership, Sun Life continues to differentiate itself, growing its marketleading Stop-Loss products and reaching an incredible milestone of doubling the size of the business over the last five years. She is supported by a tremendously talented team of subject matter experts to whom she attributes Stop-Loss & Health’s success.

Sandra Fenters CEO Capterra Risk Solutions Sandra Fenters works with entrepreneurs of closely held businesses, private equity firms, public entities, and not-for-profit organizations who seek to capture profits within their organizations by implementing solid risk management and loss prevention techniques. Jen Collier Jennifer Collier Senior Vice President, Stop-Loss Sun Life Jen Collier is stop-loss and self-funding executive with a passion for health and wellness. Her leadership experience across all core business areas fuels her successful record of accomplishment as a growth and profitability accelerator who leverages deep industry knowledge coupled with a drive for innovation. Jen joined Sun Life U.S. in June 2019 as a member of the Senior Leadership Team and Senior Vice President of Stop-

38

THE SELF-INSURER

The firm specializes in creating alternative risk transfer (ART) mechanisms and captive insurance companies. Fenters and her team provide captive management and consulting services for captive formations of all types including pure single parent, group arrangements, and association captives. The firm manages captives both within the United States and internationally, and is typically engaged to provide feasibility studies, business plan development, corporate governance, and underwriting services.

Fenters began her insurance career with a large international insurance company as a surety underwriter. Her experience spans multiple disciplines including surety, professional liability, commercial liability and high net worth personal lines insurance.

Sandra Fenters


A first-of-its-kind partnership for accountable care management Collaboration to deliver positive outcomes for injured workers Paradigm has joined forces with a top-ranked national rehabilitation hospital, Shirley Ryan AbilityLab, to form the first value-based partnership in workers’ compensation. Ensuring catastrophically injured workers achieve the best possible functional and behavioral outcomes requires collaboration with providers from the very beginning. Through this innovative new approach, Paradigm will leverage provider expertise and data at the outset of care—to establish mutual goals in the pursuit of maximum recovery. The result is true accountability and transparency that benefits injured workers and their families, while delivering value to payers.

To learn more, visit paradigmcorp.com/vbpmay


ENDEAVORS

Fenters was also a broker for a large insurance brokerage outfit and possesses her Property & Casualty insurance license. Fenters has authored numerous articles on captive insurance and was faculty for The University of Delaware’s Captive Program. Fenters is active in educating and lobbying U.S. Congress Members on the benefits of captive insurance. She is also an active member of the Self-Insurance Institute of America, Inc. (SIIA) and the Captive Insurance Companies Association (CICA), serving on committees and participating in programs and conferences.

Fenters is a graduate of Allegheny College and holds a Bachelor of Arts in Political Science and a Bachelor of Arts in English. She is also a graduate of The University of Pittsburgh Graduate School of Business Institute for Entrepreneurial Excellence, Fellows Class of 2010.

Lindsay Harris President HMA Lindsay Harris is the President of HMA. For over 20 years, she has built her career on understanding the intricacies of the American healthcare system and creating cost-effective products and solutions so that people have the knowledge and tools

40

THE SELF-INSURER

to prevent disease and ensure access to quality medical care when they are sick.

With a breadth of experience and deep expertise, Lindsay understands that for employers to offer decent benefits to their employees they must have access to affordable yet comprehensive plans.

Joining HMA in 2008 as Manager, Disease Management and Wellness Programs and then Manager, Health Promotion and Clinical Support Services she deepened her knowledge of preventive care, nutrition, and fitness. As Senior Population Health Strategist, she developed and oversaw the execution of HMA’s population health product and consulting strategy.


ENDEAVORS Promoted to Director, Strategy, Product and Customer Experience Lindsay formed the first formal Product Management organization in HMA’s 30-year history. She led efforts in developing HMA’s product strategy and creating the organization’s product roadmap. She built internal and external stakeholder consensus on priorities and launched 15 new products/ features in the first 18 months, 3 times more than in the prior 5 years.

Over the years Lindsay has embraced technology to drive the products and tools that meet the real needs of our customers. As Chief Growth Officer she grew total revenue 25% between 2017 and 2019; achieved 30% membership growth in her first 3 years, more than double the 12% achieved in the prior 4 years; Lindsay and her team drove client persistency of 97% over a 3-year period.

She inspires and is inspired by the talented people who are the HMA team. Leveraging the strengths of their experience, dedication, and energy she builds consultative teams. As President of HMA, Lindsay Harris brings optimism and resilience in an uncertain future along with a strong sense of purpose to lead the way forward.

Prior to joining HMA, Lindsay held a variety of program management, program evaluation, and consulting positions. These include roles at Premera Blue Cross, Mathematica Policy Research, and the Agency for Healthcare Research & Quality at the Department of Health and Human Services.

Lindsay is active in the healthcare & self-funded community. Lindsay currently serves as Vice Chair of the Community Board of Pacific Medical Centers in Seattle, WA. Lindsay is a member of the Self Insured Institute of America’s (SIIA’s) Industry Certification Task Force, and serves on the TPA advisory councils for several stop loss carriers.

She holds a Bachelor of Arts in Chemistry and a minor in Psychology from Knox College, graduating Phi Beta Kappa/Magna Cum Laude and a Masters’ Degree in Public Policy with a focus on Health Policy and Program Evaluation from Georgetown University.

Cheryl Kellond Chief Executive Officer Apostrophe Health Cheryl wakes up every day to build the health plan that can fix America. She’s an

inspirational client-centric leader who has delivered more than $750M in revenue from version-one technology products at both startups and marquee brands.

As CEO and co-founder, she has guided Apostrophe from an idea to a multimillion dollar mission-driven business delivering better benefits for less money to mid-sized self-insured employers across the country.

Apostrophe is a venture-backed Certified B-Corp, funded by both seasoned healthcare investors and top technology investment funds. Cheryl earned an MBA from MIT Sloan and an undergraduate degree from the University of Chicago. She’s an ultrarunner, a 3x Ironman, and a mom of four.

Karin Landry Managing Partner Spring Consulting Group Karin Landry, Managing Partner of Spring Consulting Group, an Alera Group Company, LLC, has more than 25 years of experience in the insurance, health care, risk financing, retirement and benefits industries and is proud to have eight insurance patents in her name.

Karin’s involvement with Fallon Health as a board member has allowed her even greater insight into modern health insurance and what the carriers are facing.

JUNE 2021

41


ENDEAVORS Fallon Health is a $1.5 Billion plan company that underwrites Commercial coverage, Medicare and Medicaid and owns a life insurance and health stop-loss company.

As part of her work with the organization, Karin advises on working with Accountable Care Organizations (ACOs) to risk contract. Her time with Fallon has included chairing the Governance committee and sitting on the Audit and Compliance and Finance Committees.

Karin holds eight patents in insurance, centered around forward-looking strategies for the funding of risk management. She is passionate about the need for healthcare and wellness organizations to adapt to the rapidly changing industry and landscape, rather than settling for the status quo.

Throughout her career, Karin has received several awards for her contributions to the healthcare and captive insurance Industries, including the 2015, 2016 and 2017 Power Broker Award from Risk & Insurance, the 2017 CICA Distinguished Service Award and the 2017 Profiles in Diversity Women Worth Watching Award.

Recently, Karin led Spring through its acquisition by Alera Group, the 7th largest employee benefits firm in the country. With an expanded network and resources, Spring has been able to grow its business even more rapidly.

Karin Landry

Karin is a member of several Alera Group working group, such as the benchmarking group, the captive group and the Association Health Plan group. Karin sits on the board of advisors for and is President of Bloom Insurance, a Delaware cell captive. She also teaches a course for the International Center for Captive Insurance Education (ICCIE) and is an Advisory Board Member for the World Captive Forum. Karin received a B.S.B.A from Babson College and has a graduate degree in finance from Northeastern University.

Katie McGrath Katie McGrath Head of Accident & Health Swiss Re Corporate Solutions Katie McGrath is Head Accident & Health (A&H) North America for Swiss Re Corporate Solutions. She oversees the overall growth and development of the A&H portfolio, with a direct responsibility over sales and underwriting teams.

Throughout her 25-year career, Katie has held numerous leadership positions within the Employer Stop Loss industry. Prior to joining Swiss Re Corporate Solutions, she served as Head of Specialty and Sponsor Solutions at AIG, and was responsible for sales, underwriting, claims and operations. Katie has an impressive track record of profitably growing businesses, combining technical expertise with a client-focused mindset, building high performing teams and developing new talent.

Katie holds a Bachelor of Science from Virginia Tech and an MBA from Rutgers University in New Jersey. She is a diamond member of the Self-Insurance

42

THE SELF-INSURER


Corporate Solutions You want unparalleled customer service. Employers need the right stop loss coverage. At Swiss Re Corporate Solutions, we deliver both. We combine cutting-edge risk knowledge with tech-driven solutions and a commitment to put our customers first. We make it easy to do business with us and relentlessly go above and beyond to make stop loss simpler, smarter, faster and better. We’re addressing industry inefficiencies and customer pain points, moving the industry forward – rethinking employer stop loss coverage with you in mind. corporatesolutions.swissre.com/esl

Employer Stop Loss: Limit Health Care Exposure. Advancing Self-funding Together.

Insurance products underwritten by Westport Insurance Corporations and North American Specialty Insurance Company. © Swiss Re 2020. All rights reserved.


ENDEAVORS Institute of America (SIIA) as well as leading non-profit efforts in New Jersey supporting adolescent depression and anxiety.

governance and the effective and conservative structuring of various insurance companies and self-funding vehicles.

Jerry was heavily involved with rewriting the legislation in Oklahoma creating captives. In his position with Elevate, he is an approved captive and traditional insurance company manager in multiple jurisdictions, both onshore and off.

Jerry surrounds his personal life with his wife Kristin and 4 boys. He is a licensed pilot, scuba diver, and nationwide competitor in action pistol shooting.

Jerry Messick

Jerry Messick CEO Elevate Risk Solutions Jerry has over 36 years’ experience in the insurance and alternative risk transfer industry and is a principal and CEO for Elevate Risk Solutions.

With operations in Arizona, Delaware, Oklahoma, Hawaii and New York, Elevate is a captive and alternative risk consulting and risk solution services firm that focuses on multiple industries and trade groups, as well as providing comprehensive enterprise risk management services to companies ranging from $20million to $2billion in assets. Prior to becoming CEO of Elevate, Jerry was with a national provider of alternative risk services since 1985, where he held senior management positions with responsibility for loss control, marketing, finance, and insurance company operations. He is a specialist in board

44

THE SELF-INSURER

Jerry currently serves as Past-Chairman of the Board for the Oklahoma Youth Orchestras, Founding Member and Past President of the Oklahoma Captive Insurance Association, owner of Unity Investigations, a private investigation agency focusing on nonprofit organizations, member of the Captive Insurance Committee of the Self Insurance Institute of America (SIIA), faculty member of Lawline.com, and is actively involved as a speaker and participant on various committees for both captive trade associations and nonprofit entities.

Tom Partlow President & CEO Compass Health Administrators For the past 30 years, Tom has had a successful career in the self-insurance industry, building a proven track record of achieving organizational goals for growth, profitability, and customer satisfaction.

Prior to the founding of Compass Health Tom Partlow Administrators in 2017, Tom has led two of the largest TPAs in the Western US, founded an innovative on-site clinic company and has consulted with two healthcare technology startups in the mobile monitoring and telehealth space. His passion for delivering exceptional service and healthy outcomes to the membership is evident in every element of the organizations he has led. Over the years Tom has served on several industry and charity Boards and is currently serving on the Board of Goodwill Industries of the Greater East Bay. Tom resides in the San Francisco Bay Area.


amwins.com

Benefits are an endlessly evolving landscape. Stop-loss. Skyrocketing prices. Administrative challenges. Shock claims. Amwins is your group benefits lifeline—whether you need help navigating the chaos, solving for the unique or simply looking for additional options. Our purpose is simple: Find and deliver the specialty products you want coupled with the administrative solutions you need. Broker, consultant or carrier, let us make your life easier through custom programs and expanded capabilities. Amwins has the relationships and insights to tackle what comes next.

Bring on the future – we’ll cover it.


ENDEAVORS based full-service Managing General Underwriter of specific, aggregate and integrated medical stop loss insurance for small, medium and large self-funded employers.

Kurt graduated from Indiana University’s Kelley School of Business in 1986 with a B.S. Degree in Insurance and began his insurance career performing field risk assessment for Baldwin & Lyons, an excess property & casualty insurance specialist.

Kurt Ridder

Kurt Ridder President Spectrum Underwriting Managers Kurt Ridder is President of Spectrum – a division of Companion Life Insurance Company. Spectrum is an Indianapolis-

Celebrating

In 2021

From there, he went to work as Regional Marketing Director for the former Brougher Insurance Group, the pioneer of small-group medical stop loss insurance. In the spring of 1990, he co-founded Spectrum Underwriting Managers, Inc. In late 2016, Spectrum was acquired by Companion Life Insurance Company and continues to operate independently as a Managing General Underwriter.

Kurt has served in many positions with the Self-Insurance Institute of America (SIIA), including Chief Financial Officer, President, and Chairman. Kurt is an active speaker

Don’t Settle For Standard Stop Loss Solutions At TPAC, we make sure you have stop loss that fits your unique needs. Our underwriters can deliver quotes without claims experience or individual questionnaires—building protection based on your specific needs. We’re not afraid to take on a challenge, and we’ll always work with you to find solutions. We’re changing the way healthcare is financed, disclosed and delivered. Find out how we can help you today. tpac.com

46

THE SELF-INSURER


ENDEAVORS at conferences and forums for the Self-Insurance Institute of America, the Society of Professional Benefit Administrators (SPBA), the Health Care Administrators Association (HCAA) and others. Kurt has also lobbied on Capitol Hill and in Indiana on legislation and regulation that impacts the self-insurance industry.

Bryan Russo Senior Vice President, Sales Zelis

Michael Schroeder

Over 20+ years’ experience in Sales/Operations in Software as a Service, Healthcare Services, Managed Care, Cost Containment, Payment Integrity, PPO Network Management, Group Health, Workers Compensation, Dental Electronic Payments, Member Communication and Re-Insurance.

Mike is a frequent speaker at trade associations, conferences and is published as an insurance thought leader in magazines, journals and newspapers throughout the country.

Mike Schroeder received his Juris Doctorate from The Ohio State University College of Law and received his Bachelor of Science degree in Business Management from Tulane University.

Have Lead and Managed Sales, Sales Operations, Customers Service, Account Management/Implementation, and Marketing functions.

Mike Schroeder President Roundstone Since 2005, Michael A. Schroeder has served as President of the Roundstone organization. Roundstone develops, underwrites and manages captive/self-insurance solutions.

Mike offers more than twenty-five years of insurance industry management experience. Mike delivers a track record of leading and building fast growing, innovative insurance businesses. Prior to joining Roundstone, Mike served as Vice President and General Counsel for a NASDAQ listed AM Best A rated insurance company. Mike was also the founder of a medical malpractice underwriter and shepherded its rapid growth prior to its acquisition by a large publicly traded specialty insurer. Mike held senior level executive positions with a publicly held worker’s compensation insurer, a nonstandard auto insurer and served as an associate of a Cleveland law firm.

Stephanie Whalen

Stephanie Whalen, ALMI President The Union Labor Life Insurance Company Stephanie Whalen is President of The Union Labor Life Insurance Company (Union Labor Life). Ms. Whalen leads the company's life and health group, including underwriting, sales, claims, marketing and operations functions. Union Labor Life serves labor unions, Health and Welfare funds and union members by providing signature medical stop loss insurance and services as well as group life and supplemental insurance. Prior to her role as president, Ms. Whalen

JUNE 2021

47


ENDEAVORS served as Vice President of Operations for seven years, responsible for the day-today life and health operations of Union Labor Life.

She began her career with Ullico in 1998 as a production assistant in the Direct Marketing division, and has held various other positions during her tenure with Union Labor Life. She has more than 20 years of experience in the insurance industry, and is a member of a union family.

Ms. Whalen’s commitment to learning and personal growth is marked by her earning her bachelor’s degree and following with the completion of executive training at the Wharton Business School. She also holds several insurance industry designations including AMLI (Associate, Life Management Institute), AIRC (Associate, Insurance Regulatory Compliance), and ACS (Associate, Customer Service).

A Washington, D.C. native, Ms. Whalen resides in Alexandria, Virginia and enjoys cheering for the Washington Nationals baseball team. She is a mother of three, military spouse, avid long-distance runner, and ongoing student of the insurance profession. She is actively engaged in preparing for her FLMI, and encourages others to grow, develop and perform in every aspect of their lives.

For more information including webinar details and registration on all CFA events please visit www.siia.org.

Active in her community, she has also received various awards over the years for her work with charities and nonprofits. Those awards include the Bikes for Tikes Volunteer Award in 2000, WJLA Toyota Working Woman of the Year Award in 2001 and the AOL/Unilever Chief Everything Officer Award in 2006.

From Insurance & Benefit Administration to Care Management SM

Amalgamated Family of Companies Amalgamated Life From Insurance & Benefit Administration to Care Management Insurance Company

SM

Group • Stop Loss • Voluntary

FOR PRODUCT INFORMATION PLEASE CONTACT:

marketing@amalgamatedbenefits.com Property and Casualty Brokerage

Amalgamated Life Insurance Company 333 Westchester Avenue, White Plains, NY 10604 www.amalgamatedbenefits.com

48

THE SELF-INSURER

Financial Strength Rating

A M

BEST A Excellent

Amalgamated Family of Companies Amalgamated Life s Amalgamated Employee Benefits Administrators s Amalgamated Medical Care Management s Amalgamated Agency s AliGraphics


Medical Stop Loss from Berkshire Hathaway Specialty Insurance comes with a professional claims team committed to doing the right thing for our customers – and doing it fast. Our customers know they will be reimbursed rapidly and accurately – with the certainty you would expect from our formidable balance sheet and trusted brand. That’s a policy you can rely on.

Reimbursement done right. www.bhspecialty.com/msl The information contained herein is for general informational purposes only and does not constitute an offer to sell or a solicitation of an offer to buy any product or service. Any description set forth herein does not include all policy terms, conditions and exclusions. Please refer to the actual policy for complete details of coverage and exclusions.


NEWS

NEWS FROM SIIA MEMBERS

2021 JUNE MEMBER NEWS SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to membernews@siia.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and jivy@siia.org. 50

THE SELF-INSURER


NEWS

SILVER MEMBERS H.H.C. GROUP LAUNCHES SURPRISE BILL RESOLUTION ASSISTANCE SERVICE

H.H.C. Group announced the launch of its Surprise Bill Resolution Assistance Service (SBRAS). SBRAS is designed to assist payers in states that already have comprehensive or partial balance billing laws in place, and those who will be impacted by the No Surprise Act passed in late 2020, which will go into effect on January 1, 2022. SBRAS will support payers of medical claims in negotiating appropriate payment amounts for medical bills and enable them to present a strong case should a claim go to Independent Dispute Resolution (IDR). SBRAS options include negotiation by H.H.C. Group to achieve satisfactory settlements with providers, provision of information to payers who chose to negotiate directly with providers themselves and supplying of information for payers to give the IDR entity to support their payment amount offers when disputes go to IDR. H.H.C. Group is uniquely well qualified to provide this service given its:

· 5+ years of experience successfully negotiating settlements on medical bills on behalf of payers nationally

· highly experienced, attorney, licensed health insurance adjustor negotiators

H.H.C. Group's services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, Disease Management and Pharmacy Consulting. For additional information about H.H.C. Group and our services, visit www. hhcgroup.com or contact Bob Serber at rserber@hhcgroup.com or 301-9630762 ext. 163.

CLAIMLOGIQ NAMED A

TOP WORKPLACE IN SOUTH CAROLINA

Healthcare Tech Company Adds to a Long List of Achievements in 2021.

· proprietary database with access to multiple published databases · Medical Bill Review product to identify costly errors in claims · Panel of Board-Certified Physicians and other healthcare professionals to determine whether treatments are medically necessary, medically appropriate or otherwise qualify or do not qualify for payment. (H.H.C. Group is a URAC Independent Review Organization from 2004 for Internal and External Review)

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

52

THE SELF-INSURER

CHARLESTON, S.C. – ClaimLogiq, a leading healthcare software and technology company in cloud-based payment integrity solutions, announced today that it has been recognized as one of the Top Workplaces in South Carolina. The company adds the Top Workplaces award to a growing list of achievements in recent months, including being named a Great Place to Work®, earning Microsoft® Gold Partner certification and most recently, Executive Vice President and Co-Founder Janene Hill being named to the Forbes Next 1000 Inaugural List.


What are clients saying about our EmCap® program? “You have become a key partner in our company’s attempt to fix what’s broken in our healthcare system.” - CFO, Commercial Construction Company

“Our clients have grown accustomed to Berkley’s high level of customer service.” - Broker

“The most significant advancement regarding true cost containment we’ve seen in years.” - President, Group Captive Member Company

“EmCap has allowed us to take far more control of our health insurance costs than can be done in the fully insured market.” - President, Group Captive Member Company

“With EmCap, our company has been able to control pricing volatility that we would have faced with traditional Stop Loss.” - HR Executive, Group Captive Member Company

People are talking about Medical Stop Loss Group Captive solutions from Berkley Accident and Health. Our innovative EmCap® program can help employers with self-funded employee health plans to enjoy greater transparency, control, and stability. Let’s discuss how we can help your clients reach their goals. This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.

Stop Loss | Group Captives | Managed Care | Specialty Accident ©2017 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved. BAH AD2017-09 7/17

www.BerkleyAH.com


NEWS

“We’re honored by this recognition that was awarded to us based on our employee feedback,” said Director of Human Resources and Compliance, Krystal Vargha. “ClaimLogiq acutely recognizes the relationship between our company goals, the benchmarks of marketplace success and the direct correlation that this has to our greatest assets: our employees. It’s gratifying to know that our culture of inclusion, collaboration and our constant pursuit of excellence resonates enough with our employees for us to receive top marks and the honor of being named one of South Carolina’s Top Workplaces.” The Top Workplaces list is based solely on employee feedback gathered through a third-party survey administered by employee engagement technology partner Energage LLC. The anonymous survey uniquely measures fifteen culture drivers that are critical to the success of any organization including alignment, execution and connection. "During this very challenging time, Top Workplaces has proven to be a beacon of light for organizations, as well as a sign of resiliency and strong business performance," said Eric Rubino, Energage CEO. "When you give your employees a voice, you come together to navigate challenges and shape your path forward. Top Workplaces draw on real-time insights into what works best for their organization, so they can make informed decisions that have a positive impact on their people and their business." ClaimLogiq is a healthcare payer solutions provider delivering a proactive approach to payment integrity through a powerful, simplified software platform. The software, TrueCost™, is built upon the core principles of transparency, client-driven control and flexibility. These principles enable the design of the cloud-based platform to remain ahead of the curve and evolve with the ever-changing needs of clients and a complex healthcare industry. TrueCost is an industry-disruptive tool that empowers payers to manage payment integrity on their terms to achieve incredible results on cost savings while balancing member and provider relationships. Complex claim reviews become simplified for fastest speed to pay and the software empowers users to deliver consistent, accurate and repeatable results regardless of expertise. Uniquely differentiating itself from others in the marketplace the software is able to pivot between providing SaaS, full services or a hybrid of the two in an all-

54

THE SELF-INSURER

in-one platform. The Top Workplaces award has been announced during a time of accelerated, triple-digit growth for ClaimLogiq in 2021. “This award is another testament to our ability as a company to transcend the traditional walls of an office environment and prove that nurturing a truly collaborative and inclusive culture can be healthily harnessed beyond the confines of an office space and into a hybrid workforce,” says COO, Josh Burrus. “The growth we’ve been able to achieve is because of the innovative spirit of our engaged employees who share our company core values and work together every day to make claims logical for our clients.” About Energage Making the world a better place to work together. ™ Energage is a purpose-driven company that helps organizations turn employee feedback into useful business intelligence and credible employer recognition through Top Workplaces. Built on 14 years of culture research and the results from 23 million employees surveyed across more than 70,000 organizations, Energage delivers the most accurate competitive benchmark available.  With access to a unique combination of patented analytic tools and expert guidance, Energage customers lead the competition with an engaged workforce and an opportunity to gain recognition for their people-first approach to culture. For more information or to nominate your organization, visit


Delaware’s Captive Bureau is business at the next level

In Delaware, our captive regulators are dedicated exclusively to our captive insurance clients’ needs, and work under the direction of our Captive Bureau leadership, directed by Steve Kinion.

There are 34 people working on Delaware’s Captive team. Of this total 15 are financial analysts. Under Delaware’s regulatory organization, the financial analyst is the first-line regulator who communicates with the captive manager or owner. As a result, all inquiries, business plan changes, dividend requests, and other related matters are first addressed by the analyst. The experience level of these analysts is unmatched. STEVE KINION, DIRECTOR

Call us today to speak with a team member

Bureau of Captive & Financial Products Department of Insurance Steve.Kinion@delaware.gov

302-577-5280

Our team has 15 analysts 12 hold the Associate in Captive Insurance (ACI) designation 12 hold the Accredited Financial Examiner (AFE) designation 9 hold the Certified Financial Examiner (CFE) designation 2 are Certified Public Accountants (CPA)

BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280  captive.delaware.gov


NEWS energage.com or topworkplaces.com. About ClaimLogiq ClaimLogiq is a healthcare software and technology company that delivers a proactive approach to payment integrity through a powerful, simplified software solution.

ClaimLogiq's innovative software stands out from the crowd by allowing payers client-driven control, customizability, and total transparency over the entire claim process and can be applied as a SaaS, full-services, or as a hybrid model to suit the specific needs of every payer and provider agreement. ClaimLogiq's groundbreaking technology produces more cost savings in both pre and post-pay environments and all-but-removed provider abrasion, impacting millions of lives annually in the pursuit of a higher quality of healthcare for all. For more information, visit www.claimlogiq.com or follow ClaimLogiq on LinkedIn.

The unique payer-facing, claimanalyzing solution – TrueCost™ - is HITRUST CSF® certified and makes claim reviews accessible to all size healthcare payers for in-depth insight and real-time access into the status of every claim at every stage of the audit lifecycle for controlled, consistent, accurate, and defensible outcomes, second to none.

Health Benefits Consulting Suite ( Simulate expected plan changes

and calculate precise claim rates

( Identify a risk-appropriate self-

funded structure

DELIVER MORE at Every

Step

MORE INSIGHT. MORE INTELLIGENCE. MORE VALUE.

( Calculate optimal budget rates

and model impact of forecasted enrollment Generate a refined, actuarially sound IBNR easily and quickly

Actuarial Advisor ( Build credible rates for groups of

any size

( Adjust rates precisely for changes

in every relevant input

( Incorporate complex interaction

effects between input factors

sales@clarosanalytics.com • 609.275.6500

clarosanalytics.com

56

THE SELF-INSURER

( Project first dollar, specific,

aggregate and excess risk


WRITE BETTER STOP-LOSS

FASTER Market. Bind. Administer. Renew At Ringmaster, we never stop innovating. Our forward-thinking team of professionals work diligently with our clients to continue to create solutions that not only meet the needs of today, but tomorrow and well into the future. Next generation cloud-based software designed by and for Stop-Loss procurement and administrative professionals. Deliver productivity and strategic gains to your Stop-Loss marketing and procurement teams.

Auto-generate first dollar medical and Rx reports as well as filings to Carriers and MGUs.

Seamlessly Connect the Stop-Loss Policy Lifecycle with Ringmaster Connect with us today to learn how our products will expedite your overall Stop-Loss procurement cycle 330.648.3700 • rmtsales@ringmastertech.com • www.ringmastertech.com

The New Generation of Healthcare Stop-Loss Business Process Automation


SELF INSURANCE INSTITUTE OF AMERICA, INC. 2021 BOARD OF DIRECTORS

CHAIRMAN OF THE BOARD* Robert Tierney President StarLine Osterville, MA

PRESIDENT/CEO

Mike Ferguson SIIA Simpsonville, SC

CHAIRMAN ELECT*

DIRECTORS Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ

Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston Salem, NC

Laura Hirsch Co-CEO Aither Health Carrollton, TX

TREASURER AND CORPORATE SECRETARY*

Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN

Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA

Lisa Moody President & CEO Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN  

*Also serves as Director

58

THE SELF-INSURER

SIEF BOARD OF DIRECTORS Nigel Wallbank, SIEF Chairman

Directors Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP


Being Powerful. Being Human. Being PharmPix.

Partnership is within your grasp.

Discover why PharmPix has been revolutionizing PBM since 2009. Schedule a personalized demo at www.pharmpix.com or call 404-566-2000.

POWERED BY ONEARK


SIIA NEW MEMBERS JUNE 2021

REGULAR CORPORATE MEMBERS

Bejoy Changarath Assistant General Manager PR & Media Relations Aster DM Healthcare Dubai, UAE

EMPLOYER CORPORATE MEMBERS

J.J. McBride President Lytle Signs, Inc. Twin Falls, ID

Do you aspire to be a published author? We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world.

Mary Person President Blue General Partners Dallas, TX

The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984.

Henry Juszkiewicz CEO and Founder CareMoat Inc. Nashville, TN

Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ sipconline.net

Dan Cochran VP of Sales MacroHealth Kirkland, WA

The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.

Geoff Rowson SVP Sales Totem Alpharetta, GA

JUNE 2021

60


IS 1 TRILLION

DOLLARS

in healthcare waste & errors too much?

YES. At Zelis, we listen to what payers and providers want and bring technology, people, expertise, and entrepreneurial energy together to create smart solutions and a better way for the industry. Integrated solutions to price, pay, and explain healthcare on a claim by claim basis, all offered by one trusted company.

Maximized Claim Savings. Optimized Payments. Transparent Explanations. Contact Zelis today at 888.311.3505 or visit zelis.com to find out how our pre-payment solutions are helping control the rising cost of healthcare.

Better Service. Better Performance.

zelis.com Copyright 2021 Zelis. All rights reserved.


Stability for those balancing risk and reward.

Those who self-fund a health plan seek autonomy and control over their benefits program and costs. It can be rewarding, but it does come with risk. Stop Loss protection from HM Insurance Group works to mitigate that risk for self-funded employers should high-dollar claims arise – delivering steadiness to the performance and confidence in the outcome. Find more on hmig.com.

CONNECT WITH ONE OF OUR EXPERTS ON OUR INSURANCE AND REINSURANCE OPTIONS: Employer Stop Loss: Traditional Protection • Small Group Solutions • Coverage Over Reference Based Pricing Managed Care Reinsurance: Provider Excess Loss • Health Plan Reinsurance

In all states except New York, coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA. In New York, coverage is underwritten by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. MTG-3355 (R3/21)

Profile for SIPC

The Self Insurer June  

Recommendations could not be loaded

Recommendations could not be loaded

Recommendations could not be loaded

Recommendations could not be loaded