The Self Insurer November

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Public Deception


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





By Karrie Hyatt









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

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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



Public Deception


Written By Bruce Shutan


f the pandemic taught working Americans anything at all, it was that the fine line separating work from life has considerably thinned. Many frustrations about work and life were aired on social media, which was a slippery slope even prior to Covid-19 turning the world on its head. Employees and even executives have been terminated over controversial social-media posts in the age of cancel culture. Not everything that’s shared on these popular digital platforms, of course, is negative or hateful. Social media helps people find new employment opportunities, as well as stay in touch with friends and family. But it also can land some in hot water if they have nefarious plans and end up revealing too much about their life outside of work. Case in point: workers’ compensation fraud, which costs insurers and employers an estimated $6 billion a year, according to the Coalition Against Insurance Fraud. Although rare in the work comp space relative to other types of insurance fraud, it’s important to be careful about what is classified as fraud, especially in certain jurisdictions, explains Matthew Yehling, director of claims for Midwest Employers Casualty, a Berkley company. “Having 50 different jurisdictions obviously adds a little complexity,” he says.



Public Deception

A plethora of information that’s now available online has made it much easier for adjusters to crack open suspicious cases, especially given the prevalence of the world’s most popular social-media platform which Statista estimates at 2.8 billion monthly active users.

“Think of everything that’s on Facebook,” observes Yehling, who Matt Yehling

presented on this topic at SIIA’s 2020 virtual

“People say, ‘I don’t have social media.’ Well, if you’re at a party, and your friends are taking pictures, where do you think those pictures end up? They’re on Facebook. They’re on Snapchat. They’re on Instagram.” national conference.

Similar avenues that might ensnarl low-profile or private individuals in a social media web of lies may include a fishing tournament whose results are posted online. Yehling recalls photos of someone performing in a band on a Friday night when just two days earlier “he was telling the doctor that he couldn’t do anything.” Having hard conversations about such discrepancies could go a long way toward nipping any malingering in the bud. “I’ve seen examples of that,” he reports, “and all of a sudden, the injury that may have been lingering has had a recovery.” A men’s workout group that Yehling participates in outside of work hours offers another glimpse into how employers could learn that some work comp claims may not square with the real world. The routine recording and posting of videos to what he describes as a “private” link on YouTube could easily unmask fraudulent activity. These examples, which along with a seemingly endless stream of other leisurely activities involving millions of working Americans, offer a potential treasure trove of compromising positions for those investigating work comp fraud.

SHOT IN THE ARM FOR SURVEILLANCE Simple social media checks often provide surveillance teams the ammunition they need to uncover work comp fraud, notes Erin McBride, AVP, regional claims manager for Mackinaw Administrators, LLC, who co-presented with Yehling. In many cases, she says it’s photo tagging that crack cases, especially if claimants are savvy enough not to advertise side hustles that land them in trouble.

Having worked with many surveillance companies, Yehling believes they would all agree that social media has enhanced their ability to capture smoking-gun moments. However, he suggests that employers show prudence when hiring these firms because “it can be quite costly to have somebody surveilled for eight hours a day… As an insurance carrier, the last thing I want people to think is that we’re surveilling 10,000 injured employees.” McBride has literally seen her share of false work comp claims from head to toe. In one instance, a county worker from an employer client indicated that a head injury caused ongoing headaches that kept her from working in noisy, sunlit environments.

“Somebody tagged her in a social media post where she was dancing in a nightclub with loud noises, bright lights and tons of people,” she reports. “We were able to show that video to the physician and her inconsistencies, and he actually sent her back to work, and were able to refuse further benefits after that.”



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Public Deception Another individual who worked as a parks-and-roads laborer claimed to have carpal tunnel syndrome. The problem was that a doctor who examined her couldn’t pinpoint any job duties that caused this injury. “We looked on her social media, and the adjuster found that there were a lot of pictures of cakes and cookies,” she explains. “So, we put out some surveillance feelers to try and see what this person did on the side. Come to find out, she had a cake and cookie decorating business and was doing a lot of intricate decorating.”

Erin McBride A similar case involved a woman whose foot injury prevented her from working as a corrections officer. Every time adjusters tried to contact of her, voicemails were followed by callbacks with lots of background noise that raised red flags. Her social media posts featured tagged photos that revealed a DJ side gig at weekend parties that she was careful not to promote on her own profile. It didn’t take long for investigators to catch her in the act. Surveillance video showed the DJ decked out in high heels and dancing up a storm. The evidence was shown to her doctor and attorney, proving once and for all that her disability was falsified.

The revelation was shared with her physician who identified that activity as the cause, not her job duties, which led to her claim being denied. Once again, the claimant was smart enough not to post about her activities off the clock, but overlooked tagged photos, which did her in.

RED-FLAGGED PATTERNS A common pattern that Yehling has seen with fraudulent cases is that they generally start off small, but then all of a sudden injured employees cannot lift anything at work. Red flags are raised when employers learn that claimants are lifting their grandkids or pictures of them visiting the zoo or engaged in various activities are posted on social media.

“She wasn’t savvy enough to know that if people tagged her at certain events that we would be able to find it after that,” McBride says.



Public Deception “When they go to that doctor’s appointment on Monday,” he says, “it’s not as bad as the neck collar that you used to see in those commercials, but they’re moving slowly, and they tell the doctor they can barely get out of bed.” One tricky task for investigators is to determine whether any potentially incriminating social-media posts could be misconstrued or misrepresented. For example,

“Just because you see a picture of the buffed-out guy in his headshot lifting a 100-pound weight, that could have been him from 10 years ago,” Yehling

photographs might not be current.

explains. He remembers a very different scenario unfolding with a construction worker who was also active in the Screen Actors Guild and built like Arnold Schwarzenegger had some explaining to do. Although claiming that he couldn’t lift a 10-pound weight at work, photos of the work comp claimant at a Mr. Universe-type competition were splashed all over social media. “You could figure out what days it was and where he was engaged in those activities,” he says.

He says smartphones, often the primary engine fueling social media, can be used as a tool to prove safety violations occurred when someone was injured, noting how those who are in motor vehicle accidents are among some of the worst work comp claims. “We’ve had instances of using cell phone records to track how somebody alleged a claim had occurred,” Yehling reports. “Most employers allow you to have your cell phone in your pocket nowadays, and most people have them in arm’s reach. If they’re walking around and they have a mobile job and something’s happened, that’s another potential avenue for information gathering.”

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Public Deception If somebody gets seriously injured at work and the injury is compensable, we’re always going to pay that claim. But if they’re exaggerating, or there’s some kind of activity going on that’s clearly not benefitting the recovery or the organization, then we want to make sure that we’re paying the right thing.”

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

INNOCENT UNTIL PROVEN GUILTY While there always will be attempts to defraud the workers’ comp system, McBride says a majority of claims are paid and it’s important that adjusters be objective and approach all cases from the standpoint that claimants are innocent until proven guilty. In a similar vein, she urges employers that self-insure work comp not to be overly tainted in their view of the potential for criminal activity. “We do have a responsibility to take care of the individual that’s injured, get them the best care that they need, rehabilitate them, and get them back to work,” she adds. In order for employers to help prevent work comp fraud from occurring in the first place, Yehling notes the importance of keeping open the lines of communication. That means having constructive and uplifting conversations between injured employees and their supervisors about a range of topics. Examples include how they’re approaching return to work, letting them know they’re missed on the factory floor or in an office setting, asking how they’re feeling and encouraging a positive attitude.

“The more you interact with injured employees, have those dialogues and show concern for them, I think the better the result will be,’ he believes. “I think most carriers have that mentality… 10


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Captives Find a Place Insuring Construction


he construction sector is forecast to grow exponentially over the next decade, both in the U.S. and internationally. While this is an exciting time to be in construction, the risks and exposures are increasing. As the hard insurance market is expected to continue at least through 2022, construction companies are looking to captives to insure many of their risks.

STATE OF THE MARKET Written By Karrie Hyatt



A report published in August by Research and Markets claims that the U.S. construction industry will grow by 1.8% in 2021 and by 3.1% in 2022, with an annual average growth of 2.2% through 2025. That is welcome news to an industry that suffered losses in 2020 due to the pandemic-related slowdown.

Captives Insuring Construction

While industry growth is welcome, it comes paired with a hard insurance market that is making it more expensive to insure expanding business. As it is in many sectors, the construction industry has been hard hit by sharply climbing premiums.

According to Randy Sadler, principal with CIC Services, LLC, “The U.S. construction industry has seen significant growth, but insurance rate increases are also a trend which poses a challenge in addition to increased labor and materials costs, rising health care costs.”

The COVID-19 shutdown slowed the construction marketplace in 2020 and while construction projects are now being pursued with renewed energy, COVID-19 has

“COVID created a perfect storm in the sense that construction businesses now must comply with increased regulations may face supply chain disruptions and manage travel restrictions while also ensuring safety protocol for workers. COVID has also created construction delays, or a site may be locked down and inaccessible,” said created even more challenges.


The hard insurance market is making it tougher and more expensive for constructionrelated companies to adequately cover their risks. While there are abundant new opportunities for the industry, construction companies will need to look to new ways to approach risk.

CAPTIVES AND CONSTRUCTION The hard insurance market has been an impetus for construction companies to look for an alternative to traditional insurance. However, even before the current hard market, construction was looking to captives to provide coverage for risks that are difficult to insure and to fill gaps in coverage in regular policies.

“Construction companies are uniquely suited to own their own insurance company,” said Sadler. “Commercial insurance is often riddled with exclusions that can lead to claims not being paid. Captive insurance fills those gaps and address the complex, evolving risk that members of the construction industry often face.”

Like the medical and transportation sectors, construction companies insured by traditional carriers are penalized for others in their industry who may not be so conscientious. Construction companies with a focus on risk management and safety are best suited to form a captive, freeing themselves from the cycle of premiums based on other companies’ losses.

“For construction companies, captives are a versatile solution. Captives can replace commercial insurance, insure enterprise risks, insure warranties, insure bonds, insure employee benefits or health care or any combination of these,” said Sadler. “Since captive insurance has proven to be very beneficial for construction companies, these companies now make up 20 percent of captive owners managed by CIC Services—up from 10 percent three years ago.”

Besides the common risks, such as general liability, property damage, workers’ comp, employee benefits, and supply chain interruption, construction companies face a unique set of risks. Since the vast majority of construction contractors do not have the capacity to do all the work on a project, they must subcontract out large chunks of work. This makes them liable for work that that the subcontractors’ default on or work that is defective. They are also at the mercy of fluctuating costs of materials.

Construction companies also face environmental and geologic risks, along

NOVEMBER 2021 13

Captives Insuring Construction

with fire, weather, and other natural disasters. Compliance with building codes changes or regulatory changes mid-project is another risk. Unique to the construction industry are risks related to labor shortages and seasonal slowdowns.

As the work construction companies do depends on materials over which they have no control, construction defects are a weighty risk they face. Long-term construction defect risk, whether due to materials or mistakes, can be a lengthy exposure, taking years to come to realization. Using a captive, companies can offer warranty coverage for such risks.

Construction captives can be used to insure a company’s subcontractors in the event of unfinished work or defective work. “Contractors utilize sub-contractors, and with the captive insurance arrangement, they can bond subcontractors via their captive, providing insurance coverage in the event that this third-party laborer does not complete its work,” said Sadler. “One of the most exciting benefits of captive insurance for construction companies is the ability to find a new profit center in payment and performance bonds or in subcontractor default (SDI) insurance, or both.”

Subcontractors are also beginning to make use of captives. According to Sadler, “Subcontractors often face as much risk, and similar risks, to the construction

companies. They may have multiple crews working on multiple sites at the same time, and face the risk of financial penalties if work is completed late. This risk can be insured in a captive.”

In data collected by, only 15% of construction firms have more than 1,000 employees. For these large firms, a pure captive is likely the best choice, but for most companies joining a group captive makes more sense. “Mid-sized construction companies, in particular, should consider group captives for some lines like auto liability, workers’ compensation and general liability,” said Sadler. “We don’t normally recommend managing these lines in single parent captives unless both premiums and exposures are very large, which they tend not to be for mid-market companies.”

He continued, “We often encourage construction companies to write a layer of property, work comp and general liability and other coverages through their single parent captives which offer greater flexibility.”

Forming a captive insurance company is an advantageous choice for a construction firm that has a track record of being diligent regarding safety and risk management practices, and it can be an even better choice to join



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Captives Insuring Construction a group captive with similar companies. Working together, group captives offer enhanced risk management techniques, the opportunity of a deeper understanding of risk due to larger data sets, and a better understanding of health and safety issues faced by similar companies.

With the construction sector’s forecast of strong, steady growth, it is an exciting time for the industry. It’s an exciting time for the captive insurance industry as well as it gets to tackle the plethora of new risk that the construction industry brings to the table. Captives and construction companies pair well together. As Sadler

“Captive insurance provides a stronger business model, improved risk management, improved cost control, insurance profits, asset protection, asset accumulation and receives advantageous tax treatment.” stated,

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.



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A ROSE BY ANY OTHER NAME… Written By Ron E. Peck


he year is 2009. You are busy serving as a claims administrator for a selffunded health plan, on a lovely Monday morning in March.

On this day, a couple appeals roll into your office. In one instance, a claim was denied due to a lack of medical necessity. Nothing was paid; the claim was denied in full. In the other instance, the appeal relates to an out-of-network provider’s bill.

The original claim that was submitted for payment exceeded $30,000. At the time, the applicable benefit plan paid an amount it calculated to be “usual and customary” (or “U&C”); the process it applies when determining a maximum allowable payment when there is no pre-existing contractual rate.



In the first case, the provider is filing an appeal, arguing that the treatment did meet the plan’s definition of medical necessity.

In the second case, the provider is filing an appeal arguing that the plan’s calculation of U&C is flawed.

In both cases, less than 100% of billed charges was paid. In both cases, the reduced payment (or no payment) constituted an adverse benefit determination.

In both cases, the provider – deeming itself to be a beneficiary of the plan (a completely separate discussion for another day) – has exercised its right to file an appeal. In both cases, per the terms of the plan document and applicable law, the plan will have a fixed number of days to review the appeals and issue a decision… In both cases, they can uphold the original decision, or overturn the original decision and pay something additional.

In both cases, if the decision on appeal is to uphold the original decision, the beneficiary may then choose to appeal again (if a second appeal is available), and once the appeals are exhausted, seek to appeal the matter externally to a court of law.

With the passage of what we call ObamaCare, rights to appeal were greatly strengthened. New rights were bestowed upon beneficiaries, while new obligations were simultaneously imposed upon plans and carriers.

Strict timelines were bolstered by law, and access to binding external appeals before independent review organizations (or “IROs”) were legislated. As providers and patients became more aware of these added rights and opportunities to push back against adverse benefit determinations, the number and complexity of appeals grew.

Both in response to denials and reduced payments, plan sponsors and administrators soon came to appreciate how important a well-organized and defensible appeals process truly is.

They also came to realize how risky it is to make claims payment decisions and handle appeals without outside analysis. Indeed – any seemingly arbitrary decision could, upon review, result in the decision maker being slapped with penalties for having breached their fiduciary duty.

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A year later, the “Affordable Care Act” (or “ACA”) was enacted in two parts: The Patient Protection and Affordable Care Act (signed into law on March 23, 2010) and The Health Care and Education Reconciliation Act (of March 30, 2010).

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Sadly, whomever devised this plan has apparently never negotiated before, since – any experienced negotiator knows – when entering a negotiation, you set a “cap” or maximum amount you are willing to pay (or accept).

Thus, it was that both external review of appeals and protection against fiduciary liability found new value in the eyes of payers. So it was, for more than a decade…

On Dec. 27, 2020, The No Surprises Act (or “NSA”) was signed into law as part of the Consolidated Appropriations Act of 2021. Amongst the many interesting rules and changes so introduced, the NSA seeks to prevent providers from balance billing patients in specific instances.

With that in mind, we are forced to wonder, when a patient can’t be held responsible for a balance, what – then – becomes of the balance? Is the provider forced to waive it? Is the applicable plan or carrier required to pay it? Something in the middle?

Indeed, telling providers not to bill patients was the easy part; deciding who pays what to whom – less so. The rule attempted to address this by stating that providers and payers would first be forced to negotiate.



That amount is in turn based on numerous factors. Some important – if not the most important – factors are how likely you are to “win” if a matter can’t be resolved amicably, how much you’d win, and what it would cost to win.

The rule went on to explain that if a matter can’t be negotiated, it will proceed to arbitration. The arbitrator – applying “baseball arbitration” rules – will need to pick between two offers; one made by the payer, and the other made by the provider. There can be no “middle ground” selected by the arbitrator.

The issue, again, is that – until we know what rules or parameters the arbitrator will use to determine who “wins,” then no one knows who arbitration favors or how much to offer.

Without knowing what happens if a balance is NOT settled, we can’t enter negotiations with a plan; without knowing what happens in arbitration, we can’t engage in independent dispute resolution with a plan. This left us clamoring for more information.

Recently, we received an answer. On September 30, 2021, the Departments of Health and Human Services, Labor, and Treasury, along with the Office of Personnel Management, released an interim final rule with comment period, entitled “Requirements Related to Surprise Billing; Part II.”

Here, they made clearer their stance on the use of objective pricing metrics – such as Medicare rates – and gave us some additional information to help us calculate how much is likely to be deemed the proper payment by an arbitrator.

Rather than delve more deeply into that aspect of the rule, however, I seek not to address the rules and parameters likely to determine how pricing disputes will be resolved, and rather, I seek to highlight one glaring issue… What happens to appeals?

Recall, back on that sunny Monday in 2009 when you received those two appeals? Recall how those appeals were handled in accordance with the terms of the plan document and law? It was so simple, back then… Any reduced payment would be deemed an adverse benefit determination and would be eligible for appeal.

Skip to 2021, and here we find ourselves dealing with a true issue – what is appealed, and what is not? What adverse benefit determination must be appealed, and which triggers the NSA?

Certainly, some adverse benefit determinations clearly fall into the bucket of appeals. If a claim is denied outright – regardless of network status – because the service was (for instance) cosmetic, not medically necessary, and thus excluded by the plan… the provider, if they believe the payer to be mistaken, should appeal the denial.

Likewise, looking at a situation that seems to fall cleanly under the NSA umbrella, an out-of-network specialist, providing services at an in-network facility, that treats a plan member… only to have their bill be paid based on a percent of Medicare rates (and leaving a balance behind) is the type of scenario envisioned by the NSA.



If this provider believes that the plan didn’t misapply the terms of the plan document and agrees that the amount paid by the plan matches the maximum allowable amount as defined by the plan document, then – we believe – this balance would not be eligible for appeal, and rather, would need to be disputed per the NSA.

Yet… not all claims fall so neatly into these buckets. What if a claim, submitted by such an out-of-network specialist (at an in-network facility), is denied in part due to a plan exclusion (such as experimental and investigational), and the remainder is paid using a Medicare-based pricing methodology?

Is one part (the denied part) of the claim appealed, whilst the other part (the reduced payment) is disputed under the NSA? Does this happen simultaneously? What if the denied portion of the bill is overturned, and paid – using the aforementioned Medicare-based pricing methodology?

Must this be disputed anew, or added to the other disputed payment? What if the provider is willing to accept a payment based on a percent of Medicare rates, is pleased to accept the percent of Medicare described in the applicable plan document, but believes the plan simply miscalculated the Medicare-based amount to which that provider is entitled? Is that clerical error grounds for an appeal, or dispute?

This represents just the tip of the iceberg, when dissecting the breadth and scope of adverse benefit determinations. The variety of reduced and denied payments we routinely handle in our office would shame Baskin Robbins and their mere 31 flavors.

With the creation of an alternative means to challenge a plan’s payment now being established by the NSA, in addition to the appeals process, we can expect an increase in appeal volume (as providers seek to trigger the NSA but mistakenly submit an appeal), complexity (as the players attempt to parse out what should be appealed, and what should trigger the NSA), and confusion (as matters go from an appeal of unpaid claims to a dispute over reduced payments of the same claim, following an overturned denial).

In addition to creating ambiguity and confusion regarding which disputed adverse benefit determinations trigger the NSA versus those that are eligible for appeal, so too does this also create more opportunity for conflict between benefit plans and their stop-loss carriers.

Once, stop-loss carriers only needed to suspend reimbursement while a matter proceeded through an appeals process. Now, stop-loss carriers will struggle to keep an eye on the claims as they bounce back and forth between appeals and NSA disputes.



Furthermore, while most stop-loss carriers agree to reimburse payments their policyholders are forced to pay (following an appeals process and order issues by an IRO or court of law to overturn an adverse benefit determination), will those same carriers also agree to cover additional payments made during an NSA negotiation period? Following independent dispute resolution and arbitration?

Adding to this quagmire, is the plan administrator’s fiduciary duty. Plan administrators have learned over time to handle appeals in strict accordance with applicable law and the plan document. The terms of the plan document regularly dictate what is payable, and how much is payable.

Now, are these plan administrators authorized to pay something additional during the NSA’s requisite “negotiation period,” without exceeding the authority granted to them by the plan document and Employee Retirement Security Act of 1974 (“ERISA”)? Would an additional payment during negotiations constitute a payment in excess of the maximum allowable amount, and thus, constitute a breach of their fiduciary duty?


In summary, it is safe to say that these new regulations and laws will increase the number of entities that may file appeals and broaden the scope of issues about which appeals may be filed, as well as complicate the process applicable to handling adverse benefit determinations and appeals.

Additionally, the other “dispute resolution” procedures established by law – separate and distinct from formal appeals – will result in confusion regarding which conflicts are meant to be appealed, versus those that should now be handled via an alternative methodology.

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As these rules and regulations continue to be released, we will continue to learn more. Hopefully, which claims fall into which lane – appeals versus disputes – will further crystalize. In the meantime, benefit plans and those that service them would be well advised to revisit their current appeals process.

Ensure the process clearly defines what can be appealed, when, and how. Retain objective third parties to provide a de novo review of adverse benefit determinations and share liability for complicated decisions. Establish a process by which matters can be transferred to or from the appeals process if and when it is determined a matter should be appealed, or negotiated via the NSA.

Finally, stay abreast of the changing rules to ensure compliance. Meanwhile, communicate with your stop-loss carrier to confirm what they need – before, during, and after both appeals and NSA based disputes – as well as define what is covered, when, and what documentation is required. Together, we can overcome these new complexities, and hopefully emerge with a system that works.

Ron E. Peck has been a member of The Phia Group’s team since 2006. As the Chief Legal Officer at The Phia Group, Ron has been an innovative force in the drafting of improved benefit plan provisions, handled complex subrogation and third party recovery disputes, healthcare direct contracting and spearheaded efforts to combat the steadily increasing costs of healthcare.

Considered to be not only one of the nation’s top ERISA lawyers, Attorney Peck is also viewed as one of the nation’s premier self-funded health plan consultants and health benefits attorney; lecturing at and participating in many industry gatherings including but not limited to The National Association of Subrogation Professionals (“NASP”) Litigation Skills Conference, Society of Professional Benefit Administrators (“SPBA”), the Health Care Administrator’s Association (“HCAA”), The Health Plan Alliance, and Self-Insurance Institute of America (“SIIA”).

Ron is also frequently called upon to educate plan administrators and stop-loss carriers regarding changing laws and best practices. Ron’s theories regarding benefit plan administration and healthcare have been published in many industry periodicals, and have received much acclaim. Prior to joining The Phia Group, Ron was a member of a major pharmaceutical company’s in-house legal team, a general practitioner’s law office, and served as a judicial clerk. Ron is also currently of-counsel with The Law Offices of Russo & Minchoff.

Attorney Peck obtained his Juris Doctorate from Rutgers University School of Law and earned his Bachelor of Science degree in Policy Analysis and Management from Cornell University. Attorney Peck now serves as The Phia Group’s Chief Legal Officer, and is also a dedicated member of SIIA’s Government Relations Committee.



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. The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984. Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ for advertising information.

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.



Written By Deborah Allwes Largoza, RN, MBA, MPH, President, Amalgamated Medical Care Management


ven before the pandemic, the use of telemedicine was increasing, however, COVID-19 proved a catalyst for its widespread application. According to the American Hospital Association, as of February 2019, 76% of U.S. hospitals have been connecting with patients and consulting practitioners using video and other technology. In February of 2020, the Centers for Disease Control and Prevention (CDC) issued guidance through which it recommended that healthcare providers in areas where the Coronavirus was reported offer clinical services through virtual means such as telehealth and that individuals rely on these services. The CDC’s recommendations regarding telehealth were consistent with those issued by other healthcare agencies, insurers, and policymakers, all designed to help prevent the spread of COVID-19. The use of telehealth services during a pandemic notwithstanding, telemedicine including nurse helplines, telehealth calls, and other integrated platforms offer a strong value proposition during non-pandemic periods as well.



This is especially true for self-insurers who, faced with steadily rising healthcare costs, must take every measure available to reduce their costs without compromising their health plan members’ well-being.

TELEMEDICINE TAKES OFF Over the past decade, telemedicine has grown considerably. Talking to a doctor live over the phone or in a video chat, sending and receiving messages via secure messaging, patient portals and emails are now commonplace. Also, in wide use as part of telemedicine is the use of remote patient monitoring through which doctors can check on patients at home and learn of their vitals via various electronic medical devices.

provider (i.e., a primary care doctor, specialist, hospital, urgent care facility, etc.). Both the telemedicine and nurse helpline/health information services give individuals access to information on a wide range of medical conditions drawing on the RNs’ deep clinical expertise in disciplines ranging from emergency medicine, critical care and intensive care, to psychiatric care, maternity care and pediatric care. Relying on their experience and nationally-recognized clinical data, these skilled nurses can address questions relating to general health matters, prescriptions, urgent care matters (e.g., back pain, urinary tract infections, allergic reactions, etc.), mental health episodes, as well as eye, hearing and skin problems. More recently, we have seen the rise of next generation telemedicine platforms. These platforms offer fully-integrated nurse helplines and telemedicine services, through which individuals with a medical problem or question can call into a dedicated toll-free line staffed by experienced RNs based in United States. These experienced nurses would then conduct a virtual intake, recording all contact information, symptoms, and reasons for the call. They would update the patient’s Electronic Health Record, and then triage the call by either assisting the individual directly or transitioning the call through the online platform to the next level of medical support, either to a physician, health advocate or behavioral health professional.

Similarly, using nurse helplines and information resources, individuals can call into a dedicated toll free number and speak with an experienced Registered Nurse (RN) regarding a current health episode and/or simply ask a question regarding their (or a family member’s) medical condition. These nurse helplines are available on a 24/7/365 days/year basis and facilitate a telephone triage and healthcare counseling for accessing health status, health information and/ or direction to the appropriate healthcare



TELEMEDICINE INCREASING Currently, telemedicine is used by self-insured and fully-insured plans in diverse industries. One bank, for example, reported in 2019, that its workers completed over 1,200 telemedicine appointments averaging 10 minutes a call and, 1,000 calls which resulted in their members receiving needed prescriptions much faster. In a survey conducted in conjunction with America’s Health Insurance Plans (AHIP), the Peterson Center on Healthcare KFF (Peterson-KFF) reviewed private insurers’ responses to the pandemic with a focus on telehealth usage and specifically: waiving of cost-sharing for specific telehealth services, offering or expanding mental health and/or substance use telehealth services, and establishing provider payment parity for telehealth. Among its findings were that over 30 million individuals were in plans that waived cost-sharing for all telehealth services, and 15 health plans expanded access to mental health and/or substance use via telehealth services.

The federal government too is introducing programs that support the expanded use of telemedicine. With 34 million Americans lacking broadband access, the Federal Communications Commission’s (FCC) Rural Health Care Program is taking measures to make broadband more accessible to rural areas. Additionally, almost all of the states’ Medicaid programs have some coverage for telehealth services and the Medicare program recently expanded telehealth coverage to include stroke and substance abuse patients.

Following the AHA’s lead, hospitals across the nation such as NYU Langone, the Cleveland Clinic, the Medical University of South Carolina and Oregon Health Sciences University are instructing patients with potential Coronavirus symptoms to use telemedicine first before heading to a physician’s office, urgent care facility or hospital.


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TELEHEALTH USER DEMOGRAPHICS According to data collected by the CDC, from January to March 2020, 93% of telehealth patients used telehealth services for conditions other than COVID-19. As concern over the Coronavirus grew, more users of telehealth services began citing concern over potential infection as at least one of the reasons for their use of telehealth services. In 2019 and 2020 respectively, 66% and 69% of telehealth encounters involved adults age 18 to 49 years with females representing 63% of those individuals in both years.

TELEMEDICINE AND SELF INSURERS Based on data published by Statista Research Department on October 13, 2020, 61% of U.S. workers are covered by self-funded health insurance plans. Organizations elect to self-insure as a way to contain their healthcare costs. Rather than paying premiums to an insurance carrier, they are responsible for paying their plan members’ healthcare claims. The self-insurers’ savings are a direct function of how many claims must be paid. Using telemedicine, self-insurers can reduce their healthcare costs by giving their plan members more efficient, lower cost healthcare options such as a nurse helpline, telehealth physician consultation and/or the use of an integrated telemedicine platform. It is estimated that 70% of all in-person physician visits can be avoided using one of these options and, perhaps and more importantly, 90% of telemedicine calls result in the elimination of an in-person physician, Emergency Department or urgent care facility visit. By eliminating unnecessary healthcare provider visits, lower co-pays, and coinsurance costs result.

To illustrate the potential savings, the Society of Human Resource Management (SHRM) reported on the success of the National Rural Electric Cooperative Association (NRECA) with its telemedicine program. It found that for every dollar spent, its telemedicine program saved $6 based on employees surveyed at the end of every telemedicine visit, who said they would have gone to an urgent care facility or the Emergency Department if they did not have the telemedicine option. For self-insurers with so-called “frequent flyers” (i.e., individuals who rush to the doctor’s office or urgent care facility frequently), telemedicine can really deliver significant savings. In addition to these benefits to both he self-insurer and plan members, nurse helplines, telehealth physician consultations and online telemedicine platforms also have been shown to reduce employee absenteeism by giving employees a fast and convenient way to address a health concern before symptoms worsen and a medical condition becomes a more serious matter requiring time off.

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. 30



Rather than having to make an in-person appointment, which often takes longer to schedule, employees can access a nurse helpline immediately and then, if needed, schedule a telehealth call with a physician, and be directed to a hospital Emergency Department only if necessary. Given that the average wait time in an Emergency Department is four hours and that 75% of physician practices close their offices by 6 PM on weekdays with no weekend hours, telemedicine options are clearly more convenient and efficient.

INCREASING YOUR TELEMEDICINE ROI To gain the maximum return from the use of a nurse helpline/health information service, telehealth and online telemedicine platform, self-insurers should take measures to optimize their programs, including: -Seek out the right partners. For nurse helpline services, make sure that the service is staffed by experienced RNs (minimum of 20 years clinical experience) with expertise across a wide range of clinical disciplines, and nurses who demonstrate both clinical competency, as well as key human traits, including patience,

compassion and the ability to effectively communicate. -Educate plan members about the role of each telemedicine tools (i.e., nurse helpline, telehealth physician consultant, online platform) and, when and how to use them. Make sure they understand that using telemedicine does not mean they do not have he option of also having in-person healthcare provider appointments, but rather that telemedicine can often eliminate a less convenient in-person visit. Advise them as to how telemedicine is an extremely effective tool for managing chronic illnesses on an ongoing basis. Raise their awareness as to how telemedicine reduces their costs, as well as the plan’s costs.

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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

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-Survey plan members on a regular basis (monthly, quarterly, semi-annually, and annually) to measure their use of the nurse helpline, telehealth physician calls and/or online platform, and to gauge their satisfaction with the service. If adjustments need to be made, act promptly to address plan members’ concerns, problems with these options or to correct any misconceptions.

CLOSING REMARKS One telemedicine provider estimated that for a 1,000-employee company, telemedicine can redirect employees away from 44% of urgent care visits and 35% of doctor visits. Then, using its average of 140 telemedicine calls per 1,000 employees over the winter season, the employer would save $15,000 during the winter. For this same group of 1,000 employees, who would average approximately 70 telemedicine calls during the spring, the savings would be an estimated $14,728. Similarly, savings due to avoiding unnecessary physician appointments and/ or urgent care of Emergency Department visitrelated savings could be gained over the summer and fall months.



The Huron Consulting Group estimates that the number of telemedicine consultations will reach 160 million cases by 2020; a 700% increase from 2015. The pandemic has likely increased this projection. With telehealth virtual consultation savings averaging $100 per visit and generating significant savings for both plan sponsors and their members, it is likely that more self-insurers will begin relying on these extremely cost-effective, convenient, and responsive health services.

As President of Amalgamated Medical Care Management, Deborah Allwes Largoza oversees all aspects of the company’s business operations and clinical services which include Utilization Management, Disease Management, Case Management, Nurse Helpline/Health Information and Independent Review Organization. She brings extensive clinical and business expertise to the role and experience managing healthcare utilization for large member groups applying claims analyses, benchmarking, member interventions and strategic partnerships.





IIA ends 2021 with a unique gathering of industry leaders and innovators in the form of a crowdsourcing event, December 6-8th at the Belmond Charleston Place Hotel in Charleston, South Carolina.

Participate in series of kitchen table style discussions in which attendees are encouraged to openly to provide their ideas, commentary, and potential solutions for some of the most important topics in the self-insurance industry:




Price Transparency


Market forces and cost pressures combined with new regulatory requirements are leading to greater health care price transparency, but what will the new environment really look like and how should your company be positioned? Shaun Peterson Head of Employee Benefit Pricing Voya Financial


Cell & Gene Therapies Scientific advancements continue to accelerate in the area of cell & gene therapies. That’s great news for patients, but it’s more complicated for selfinsurance industry stakeholders. So what’s the plan to prepare?

Dr. Stacy Borans Founder and Chief Medical Officer Advanced Medical Strategies

Specialty Drugs Growth in specialty drugs entering the market is at all-time high, and with it, hefty price tags for highly targeted patient populations. This has been a hot topic within the self-insurance industry for several years, but what does it mean for the selfinsurance industry, how does it better manage these costs, and what’s ahead?




Jay Ritchie Chief Executive Officer Tokio Marine HCC Stop-Loss


Jim Vertino Chief Executive Officer EBMS, LLC Workforce Development Business is a team sport, so how do you make sure you have the right players and keep them motivated? Let’s share our experiences with recruiting, mentoring, succession planning, diversity, and more to get our teams ready for the 2022 season.


Kari Niblack President & CEO ACS Benefit Services

Technology Strategies In the post COVID world, we are all digital disrupters now to some degree …so what’s next in terms strategic technology strategies for companies involved in the self-insured marketplace?



Crowdsourcing is a new format for SIIA and we anticipate the conversations to be lively and candid. Sessions will be hosted by industry leaders with a deep understanding of their respective topic with a role of setting the stage for the discussion by asking thoughtful questions and furthering the group’s conversation.

Complimenting these discussion forums will be an exhibit area as well as multiple networking functions.

For exhibit/sponsorship information, please contact Justin Miller at jmiller@

To register visit

HCC Life Insurance Company operating as Tokio Marine HCC - Stop Loss Group

We Know... Risk We study it, research it, speak on it, share insights on it and pioneer new ways to measure it. With underwriters who have many years’ experience as well as deep specialty and technical expertise, we’re proud to be acknowledged as experts in understanding risk. We continually hunt out fresh approaches, responding proactively to market changes, and bringing new flexibility to our products. Our clients have been benefitting from our expertise for over 45 years. To be prepared for what tomorrow brings, contact us for all your medical stop loss, captive, Taft-Hartley and organ transplant needs.

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Tokio Marine HCC - Stop Loss Group A member of the Tokio Marine HCC Group of Companies TMHCC1154- 08/2021


NEWS FROM SIIA MEMBERS 2021 NOVEMBER 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 All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at 40



PHOENIX, AZ — Vālenz®, the innovators behind the industry’s most transparent, data-driven ecosystem for providers and payers in healthcare, recently announced that Brandy Robinson has been promoted to Client Services Executive. Robinson’s new role – under the leadership of Brian Campbell, Vice President of Client Services – will involve working closely with Valenz Assurance clients, both providers and payers, to deliver a complete, customizable range of solutions that ensure credentialing compliance and payment integrity for every claim and episode of care. Robinson’s promotion comes four years after joining Valenz as an account manager.

business and financial health is what Brandy does best.” Robinson agrees that listening and collaborating with clients is key to mutual success. “Through Valenz Assurance we are absolutely committed to ensuring provider credentialing excellence and clean claims to improve our clients’ experiences and outcomes – whether they are providers, payers or patients,” said Robinson. “I think my clients have always valued business partners who listen carefully and give honest, thoughtful feedback and recommendations born from years of industry experience.” Robinson first joined the firm in 2017 and brings 15+ years of experience as an account executive in sales. She has a degree in Human and Consumer Sciences from Ohio University.

“Valenz is consistently named one of America’s fastestgrowing private companies, and I am thrilled to be part of it,” she said. “Harnessing the value of transparency and trust with a client-centered team paves the way to smarter, better, faster healthcare.”

“Brandy brings a versatile range of talents to the table, including excellence in client service,” said Campbell. “She listens to individual client needs and delivers on her promises. That is how you build relationships for the long term, and connecting people with services that improve

NOVEMBER 2021 41


PHOENIX, AZ — Vālenz®, the innovators behind a data-driven ecosystem of solutions that lower costs while improving quality and access for self-funded health plans, recently promoted Eric Hanna to the position of Vice President, Claim and Access Solutions. Eric brings 15 years’ leadership experience in implementation management and claims analysis at Valenz, as well as expertise in business, finance and client services.

“With his deep claims, data and implementation expertise, Eric keeps his eye trained on the goal of client success,” said Amy Gasbarro, Valenz Chief Operating Officer. “After 15 years with our firm, he has proven time and time again that he is always focused on the future of network strategy and innovative medical cost containment solutions for the selfinsured employer.”

Eric brings leadership experience working with self-insured employers, third-party administrators and brokers in the areas of network strategy, claim management, employee benefits design and implementing technology solutions to streamline and accelerate claim operations. “I’ve long considered it an honor to be part of the Valenz team and having the opportunity to help our clients achieve greater levels of cost containment while improving the health outcomes of their

Today, I am proud to join the leadership team to accelerate ecosystem expansion for smarter, better, faster healthcare in the self-insured industry.”

members,” said Eric. “

Before his promotion to Vice President, Eric most recently served as Director of Networks and Implementation at Valenz. In 2019, Eric was selected for the prestigious Valenz Extended Leadership Team (ELT). He is a Certified Professional Coder (CPC) in claim coding and graduated Cum Laude with a bachelor’s degree in Business Administration and Management from Northern Arizona University.



THIS YEAR MARKS COMPANION LIFE INSURANCE COMPANY’S TH 50 ANNIVERSARY. WE HAVE A LOT TO CELEBRATE. Fifty years of securing successes and overcoming challenges. Five decades of developing a strong and stable company. Half a century of building strong partnerships. We’re not only remembering our past. We’re also looking to the future. Let us help you grow your business in the years to come. We can help give you the products and solutions you need. We’re here for you. STOP LOSS INSURANCE LIMITED BENEFIT HEALTH INSURANCE SHORT TERM LIMITED DURATION INSURANCE GROUP SUPPLEMENTAL EXPENSE INSURANCE MEDICARE SUPPLEMENT INSURANCE LIFE INSURANCE DENTAL INSURANCE SHORT TERM DISABILITY INSURANCE LONG TERM DISABILITY INSURANCE VISION INSURANCE CRITICAL ILLNESS INSURANCE

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PHOENIX, AZ — Vālenz® announced the appointment of Chris Shoffner as Vice President, Business Development. With nearly 20 years’ experience as an advocate for re-imagining employee benefits to achieve better costs and outcomes, Shoffner’s expertise aligns well with the mission of the Valenz ecosystem.

“Chris is extremely knowledgeable and passionate about creating a world where employees and employers benefit from health plans that deliver better care at lower costs,” said Rob Gelb, Chief Executive Officer at Valenz. “His expertise and decades-long track record of pushing for positive change in health plans and the self-funded insurance industry align well with the culture here at Valenz, where every decision we make is designed to enable smarter, better, faster healthcare.” Before joining Valenz, Shoffner held leadership roles in healthcare consulting and fiduciary services, where he honed his expertise in executive intelligence aimed at improving health plan design, risk management, population health and health literacy.



His specialties include healthcare tax codes, health plan design, disease management, risk management and strategic planning – “all the things health plan fiduciaries should be concerned about today,” Shoffner said. In 2008, Shoffner was selected by North Carolina state legislators and the Commissioner of Insurance to serve on the 2008-2010 Blue Ribbon Task Force for the state’s health plan. That experience, combined with his extensive knowledge of health plan management and oversight, inspired him to run for the North Carolina House of Representatives in 2016, with his platform heavily focused on controlling healthcare costs.




WELLESLEY, Mass. -- Imagine you or a family member are diagnosed with cancer, a heart condition, or are suffering from long-term COVID-19 complications. Receiving the diagnosis alone is emotional and overwhelming.

“I’ve long been a proponent of using data to make good decisions, to indemnify patients from balance billing and protect health plan assets in ways that save money for payers as well as patients and providers,” said Shoffner, adding that it was this mutually shared philosophy that drew him to Valenz. “Within the Valenz ecosystem, transparent, data-driven decision enablement is already there, and it’s actionable – both from the top-down employer level and for ensuring plan members choose highquality, lower-cost providers who will deliver the best care for them as individuals.” Nathan Nelson, Senior Vice President of Growth at Valenz, says Shoffner embodies the innovative, can-do mindset that has made Valenz one of the fastest-growing private companies in the country. “We are very excited to welcome Chris aboard,” Nelson said. “I speak for the entire executive team when I say we have every confidence in him to move us even further forward in assuring everyone in our ecosystem is strong, vigorous and healthy.” About Vālenz Vālenz enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz offers transparency through data to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate employees to optimal care solutions for substantial cost savings and improved health outcomes. More information is available at Valenz is backed by Great Point Partners. Visit valenzhealth. com.



Now you are faced with the daunting and time-consuming task of finding and accessing the right care. It can be difficult and stressful – but it doesn't have to be. Sun Life has launched Health Navigator powered by PinnacleCare to help people navigate the complex healthcare system to get medical opinions, find the right specialists and treatment centers, schedule appointments, and even track down medical records or documentation from various providers. Health Navigator offers a human-tohuman concierge approach to help people confirm that they have the right diagnosis and understand their treatment options so they can make fully informed decisions, leading to better healthcare experiences and improved health outcomes. Personal Health Advisors give members high-touch, one-on-one support and guidance throughout their healthcare journey, leveraging relationships to

NEWS connect them to the right medical providers from an extensive, national network of centers-of-excellence and top experts who specialize in their specific condition.

can't provide the level of attention and care offered by our Health Advisors who access our team's years of experience curating medical intelligence. By bringing care navigation to more workers and their families, we will expand access to care and help people make the best possible choices about their health."

A team of highly trained physicians, nurses and other medical experts provide support behind the scenes, offering in-depth medical knowledge and deep expertise in nuances of the healthcare system.

"When navigating the healthcare system, people need an advocate who can ensure they are being seen and heard, particularly when facing a serious health condition," said Jen Collier, R.N., senior vice president of Stop-Loss & Health at Sun Life U.S. "Health Navigator not only helps people manage their healthcare journey, it gives them peace of mind and support during a challenging and often scary time in their lives. As someone who has worked within the healthcare and health insurance sectors, I know that health navigation is invaluable and uniquely personal. We are thrilled to expand access to our self-funded clients and their medical plan members."

Sun Life is offering the Health Navigator with stop-loss coverage, which covers high-dollar medical claims for employers who self-fund their health plans. Sun Life's holisitic approach helps the member with improved care and health outcomes that at the same time can lower costs for both member and employer.

"High-touch care navigation is not typically available to most people, even though they should be offered to anyone confronting a serious diagnosis" said Miles Varn, M.D., CEO of PinnacleCare. "Digital rolodexes and standardized computer algorithms

Sun Life is the largest independent stop-loss provider in the U.S., according to data contained in the 2020 NAIC

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NOVEMBER 2021 47


Accident and Health Policy Experience Report. An independent stop-loss provider is defined as one that does not also sell medical claim administration services. Sun Life acquired PinnacleCare in July. As the new Health Navigator rolls out through Sun Life's employer clients, PinnacleCare will continue supporting its individual clients who have engaged their services directly.


WELLESLEY, Mass., BOSTON and TORONTO -- Sun Life Financial Inc., through its U.S. business, has entered into a definitive agreement to acquire DentaQuest, for US$2.475 billion. Headquartered in Boston and founded in 2001, DentaQuest is the largest provider of Medicaid dental benefits in the U.S. with growing Medicare Advantage, commercial and U.S. Affordable Care Act (ACA) exchange businesses. Currently DentaQuest has more than 33 million members in 36 states and approximately 2,400 employees. Upon close of the transaction, DentaQuest will become part of the Sun Life U.S. business. Sun Life U.S. currently offers dental benefits through employers for their employee benefits plans and has an extensive national commercial dental network. The acquisition of DentaQuest aligns to Sun Life's business strategy of being a leader in health and group benefits.

"We're excited about the acquisition of DentaQuest and expanding our leadership into the U.S. dental benefits space," said Kevin Strain, President and CEO of Sun Life. "DentaQuest is a values-driven industry leader dedicated to improving oral health, with a focus on underserved populations and access to dental care. The addition of DentaQuest is consistent with our strategy to focus on health and group benefits in the U.S. More importantly, it supports both our Purpose to help Clients achieve lifetime financial security and live healthier lives and our sustainability focus on improving health and wellness outcomes for all." Upon close, DentaQuest will more than double the size of Sun Life's U.S. employee benefits business by revenues and will position it as a leader in providing government



dental benefits, alongside another leading business at Sun Life U.S., its medical stop-loss business. "DentaQuest is a great organization that provides high-quality dental care and insurance benefits to tens of millions of people in the United States, with an emphasis on government programs, a fast-growing segment that now rivals the size of the employee benefits space," said Dan Fishbein, M.D., President of Sun Life U.S. "DentaQuest brings Sun Life a leading dental business, and we plan to build on DentaQuest's strength in dental programs along with Sun Life's national commercial provider network and distribution team. DentaQuest's strong values are highly compatible with our own, focused on delivering quality oral health care to all communities. We're thrilled to have DentaQuest's team join us." "DentaQuest's combination with Sun Life marks an important next step in our longterm transformation that will enhance and broaden our existing capabilities," said Steve Pollock, President and Chief Executive Officer of DentaQuest. "A variety of longstanding barriers have created significant unmet oral health needs, which are disproportionately felt by historically marginalized groups. With support from Sun Life, we will be even better positioned to fulfill this critical need, and we look forward to partnering with them as we begin this exciting next chapter." Over the past 20 years, DentaQuest has pioneered a differentiated approach to oral health that emphasizes prevention, innovation and expansion of value-based solutions, with a focus on underserved communities.

NEWS DentaQuest innovated its Preventistry® model, which aligns providers, payors and members by focusing on access, quality care and measurable outcomes, with its broad and deep Medicaid dental network in the U.S. and its proprietary claims management system, Windward. In addition to its leadership in Medicaid and Children's Health Insurance Programs (CHIP) programs, DentaQuest has seen robust growth in its Medicare Advantage and other segments, including offerings through health plan partners, as well as individuals on the U.S. ACA healthcare exchanges. Dental benefits are the second-most popular benefit after health insurance and are growing in importance because of the correlation between oral and overall health. Dental benefits programs continue to be an area of growth in employer and government benefits programs. Millions of Americans, especially lowincome populations and the elderly, have insufficient access to dental care and benefits, spotlighting the importance of the work that DentaQuest does. The transaction will also enable CareQuest Institute for Oral Health ("CareQuest Institute") to expand on its strategic priorities in support of its mission. CareQuest Institute, the current parent organization of DentaQuest, is a U.S.based nonprofit organization that seeks to advance a more accessible, equitable, and integrated oral health system, particularly for underserved communities. DentaQuest and CareQuest Institute will continue to work closely together

following Sun Life's acquisition of DentaQuest. CareQuest Institute plans to deploy the proceeds from the transaction into programs and initiatives that advance its mission. "Today marks an important milestone in our journey with DentaQuest to improve the oral health of all, and we believe that Sun Life is the right partner for DentaQuest going forward given their similar cultures and shared purpose," said Myechia MinterJordan, MD, MBA, President and Chief Executive Officer of CareQuest Institute. "The transaction will also enable CareQuest Institute to expand on our strategic priorities in support of our mission. We are pleased that CareQuest Institute and DentaQuest will continue to work together closely so that we can advance our mission of creating a more accessible, equitable, and integrated health system." DentaQuest's minority shareholder, Centerbridge, will also be selling its stake in DentaQuest. "It has been a great pleasure to work so closely with Steve Pollock and the DentaQuest management team, who stand out for their exceptional skill in delivering value for customers, members, and all stakeholders, always in constant pursuit of DentaQuest's important mission," said Dan Osnoss, Senior Managing Director of Centerbridge. "We are also honored by our association with our partners at CareQuest Institute, who make critical contributions to the wellbeing of so many people. Sun Life is a fantastic home for DentaQuest with complementary capabilities and an aligned mission, and we look forward to their success together." About Sun Life Sun Life is a leading international financial services organization providing insurance, wealth and asset management solutions to individual and corporate Clients. Sun Life has operations in a number of markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of June 30, 2021, Sun Life had total assets under management of C$1.36 trillion. Visit Sun Life Financial Inc. trades on the Toronto (TSX), New York (NYSE) and Philippine (PSE) stock exchanges under the ticker symbol SLF. In the United States, Sun Life is one of the largest group benefits providers, serving more than 55,000 employers in small, medium and large workplaces across the country. Sun Life's broad portfolio of insurance products and services in the U.S. includes disability, absence management, life, dental, vision, voluntary, supplemental health and medical stop-loss. Sun Life and its affiliates in asset management businesses in the U.S. employ approximately 5,500 people. Group insurance policies are issued by Sun Life Assurance Company of Canada (Wellesley Hills, Mass.), except in New York, where policies are issued by Sun Life and Health Insurance Company (U.S.) (Lansing, Mich.). Visit

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About DentaQuest DentaQuest is a purpose-driven oral health care company dedicated to improving the oral health of all. We do this through Preventistry® – our all-in approach to better care, expanded access, value-based financing, and innovative solutions. We manage dental and vision benefits for 30+ million Americans and direct patient care through our network of more than 75 oral health centers in six states. We provide outcomes-based, cost-effective dental solutions for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals nationwide. And, we've invested more than $230 million in grants, programs and other corporate citizenship efforts to achieve measurably healthier communities across the country. By advancing prevention-focused oral health, we will achieve better overall health for everyone. Visit About CareQuest Institute CareQuest is a national nonprofit championing a more equitable future where every person can reach their full potential through excellent health. We do this through our work in grantmaking, research, health improvement programs, policy and advocacy, and education as well as our leadership in dental benefits, care delivery, and innovation advancements. We collaborate with thought leaders, health care providers, patients, and local, state, and federal stakeholders, to accelerate oral health care transformation and create a system designed for everyone. Visit




PITTSBURGH – Following its annual financial review, AM Best has upgraded the Long-Term Issuer Credit Ratings (Long-Term ICR) to “a+” (Excellent) from “a” (Excellent) and affirmed the Financial Strength Rating (FSR) of A (Excellent) for HM Life Insurance Company, HM Life Insurance Company of New York and Highmark Casualty Insurance Company, all part of HM Insurance Group (HM). The outlook for all ratings is stable. These ratings reflect balance sheet strength, which AM Best assesses as strongest, as well as adequate operating performance, limited business profile and appropriate enterprise risk management (ERM).

“We are pleased to see AM Best’s continued acknowledgement of our financial strength,” Caleb Knier, chief financial officer, HM Insurance Group, said. “When you’re in the business of providing protection against the financial impact of catastrophic medical claims, you want your brokers and clients to have confidence in your ability to meet your obligations. These ratings help to reinforce our customers’ trust that HM is a stable, well-capitalized carrier.” The companies of HM Insurance Group were reviewed as part of the annual evaluation of Highmark Inc., of which HM is a diversified business.



NEWS By removing hazardous organic pollutants from water, Pharem Biotech can help by eliminating substances like pharmaceutical waste that enters rivers, lakes and drinking water, which can have devastating effects on underwater wildlife, as well as human health. Current trends indicate that pharmaceuticals leaking into waterways could increase by two-thirds before mid-century and The World Health Organization has identified this as one of the five top challenges facing the future of humanity.

About HM Insurance Group HM Insurance Group (HM) provides insurance and reinsurance coverage to protect businesses from the financial risk associated with catastrophic health care costs. A recognized leader in Employer Stop Loss, the company delivers protection for a range of group sizes. HM also offers managed care solutions, including Provider Excess Loss insurance and Health Plan Reinsurance. HM Life Insurance Company, HM Life Insurance Company of New York and Highmark Casualty Insurance Company are all rated “A” (Excellent) by AM Best Company. Through its insurance companies, HM Insurance Group holds insurance licenses in 50 states and the District of Columbia and maintains sales offices across the country. Visit


Driven by our dedication to resiliency in communities, QBE North America, a national provider of medical stop-loss to self-funded employers, was proud to join forces again with Leading Cities to identify and propel some of the world’s most promising startups, addressing a multitude of challenges facing cities everywhere. The 2021 QBE AcceliCITY Resilience Challenge concluded with the City Solution of the Year awarded to Pharem Biotech, an innovative cleantech company with a highly efficient and sustainable approach to water treatment.

The $100,000 award was presented following a four-day intensive boot camp and panel evaluation from representatives of the World Economic Forum, United Nations, Arsht-Rockefeller Foundation Resilience Center, QBE Ventures, and QBE North America. Part of our QBE DNA is to take care of people and communities and fostering a more resilient and sustainable world is one of the ways that we accomplish this mission. About QBE QBE North America is a global insurance leader focused on helping customers solve unique risks, so they can focus on what matters most. Part of QBE Insurance Group Limited, QBE North America reported Gross Written Premiums in 2020 of $4.8 billion. QBE Insurance Group's 2020 results can be found at Headquartered in Sydney, Australia, QBE operates out of 27 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New

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NEWS Rx solution that resulted in close to 70% savings on specialty Rx. In addition, employers use an innovative reference-based pricing strategy, and many have introduced Studio Sweat, an on-demand workout tool for employees. These forward-thinking strategies have resulted in lower overall costs, which can benefit the employers, employees, and the entire captive program.

York, conducts business through its property and casualty insurance subsidiaries. The actual terms and coverage for all lines of business are subject to the language of the policies as issued. QBE insurance companies are rated "A" (Excellent) by A.M. Best and "A+" by Standard & Poor's. Additional information can be found at or follow QBE North America on LinkedIn and Twitter.



Hamilton Square, NJ – Berkley Accident and Health, a Berkley Company, is proud to announce Cost Plus Advisors as the winner of our 2021 Berkley Edge Excellence in Health Risk Management award. The Excellence in Health Risk Management award recognizes a stop loss group captive program that has demonstrated strong health risk management strategies and best practices over the past year. This award was announced at this year’s Berkley Captive Symposium. This year’s award was awarded to the Cost Plus Advisors program for its dedication to the continual improvement of its health risk strategy. As part of Cost Plus Advisors’ ongoing health risk strategy, all employers in the program use the Cost Plus Model three-prong Rx program, which features a specialty



“No one solution is a silver bullet. When you put the right risk management pieces together with a group captive program, the results are really, really powerful,” said Bob Duch, Principal and Co-Founder of Cost Plus Advisors, a OneDigital company. “The whole program is truly greater than the sum of its parts. We’re constantly looking at our strategy and evaluating new solutions to make our program better. And our members are doing the same thing – always looking at their health expenses and plowing the savings back into improving the health benefits for their employees. Our members have seen lower claim costs. The captive program is the icing on the cake, because it enables what we do on the claim side to reduce the fixed cost side. It truly is a 1+1=3 scenario.”

NEWS About Berkley Accident and Health Berkley Accident and Health is a member of W. R. Berkley Corporation, a Fortune 500 company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captive, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. Visit

Contracting at BeechStreet, acquired by MultiPlan. Lockwood is a native of New York and is active in Boy Scouts of America at the local and national levels. She currently calls Tampa, FL, and Amarillo, TX home, splitting time between both cities. Lockwood has two children and two grandchildren.


AMARILLO, TX - OccuNet is pleased to announce the addition of Carol Lockwood as Chief Production Officer. Carol has held various progressive leadership roles throughout her distinguished career in the healthcare industry. Lockwood has extensive experience within several healthcare market segments such as accident and health, commercial group health, workers compensation, pharmacy benefit management, and dental. As Chief Production Officer, Carol will lead OccuNet's overall contract strategy and emerging market opportunities, focusing on delivering new and innovative solutions to OccuNet’s valued clients and partners. "Carol is a wonderful addition to our leadership team," says Caleb Fairly, President of OccuNet. "Her wealth of industry knowledge and resources, combined with a track record of delivering exceptional client success, makes her a perfect fit as our company continues to evolve and our solutions within the healthcare industry expand." Lockwood is no stranger to the company, having served as the Chief Operating Officer of FairosRx, OccuNet's Pharmacy Benefit Management solution, for the past year. "I'm excited to begin delivering the greatest savings available to all medical bill payers and to do so as easily and efficiently as possible," says Lockwood. "The culture here at OccuNet is something I've never experienced before. I am more motivated than ever to help deliver results to our clients while contributing to the development of our growing team and client-first culture. OccuNet is a special place." Carol joined the OccuNet company following eighteen years at Zelis, formerly GlobalCare. At Zelis, she served as Vice President of Product and Vendor Management, in addition to leadership roles within Network Development, IT, and Operations. Before Zelis, she served as Assistant Vice President of National

About OccuNet OccuNet is a healthcare innovation company that creates solutions to make healthcare more intelligent, simple, and cost-effective. OccuNet provides a wide array of cost containment solutions to help manage and reduce rising healthcare costs while improving the health and well-being of those we serve. Founded in 1998, OccuNet has 20 plus years of established history, successfully building comprehensive healthcare cost containment solutions. Visit and call (877) 880-2126.




Eagan, MN – Smart Data Solutions, a Minnesota based clearinghouse and medical collateral processing and workflow automation company, announced they have earned the Certified status for information security by HITRUST.

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NEWS HITRUST CSF Certified status demonstrates that the organization has met key regulations and industry-defined requirements and is appropriately managing risk. “Organizations, like ours, are under more pressure than ever to meet complex compliance and privacy requirements,” said Patrick Bores, CIO at Smart Data Solutions. “We are pleased to demonstrate to our customers the highest standards for protecting sensitive data and information by achieving HITRUST CSF Certification.” Lyndsey Guthrey, Compliance Manager at Smart Data Solutions, added, "We have a relatively mature compliance program and the HITRUST CSF certification process verified that our compliance program is providing the necessary oversight and supporting documentation."

“In today’s ever-changing threat landscape, HITRUST is continually innovating to find new and creative approaches to address challenges,” said Jeremy Huval, Chief Innovation Officer

“Smart Data Solutions’ HITRUST CSF Certification is evidence that they are at the forefront of industry best practices for information risk management and compliance.”


This achievement places Smart Data Solutions in an elite group of organizations worldwide that have earned this certification.

Does managing specialty costs feel like a balancing act?

Script Care’s Flexible Specialty Copay Program (FSCP) offers the best of both worlds. Specialty costs are tricky: Lean too hard on copays and members can no longer afford their medications – leading to expensive medical complications. But if copays are set too low, the plan is left shouldering additional costs for these expensive medications.

Script Care’s FSCP helps navigate this troublesome cost dilemma: Our team of specialists secures every available penny of copay assistance for members and, at the same time, the program reduces the plan’s overall specialty costs by as much as 22%!

Find balance in your specialty plan - contact us for your free specialty savings analysis today! // 800.880.9988




NEWS By including federal and state regulations, standards, and frameworks, and incorporating a risk-based approach, the HITRUST CSF helps organizations address these challenges through a comprehensive and flexible framework of prescriptive and scalable security controls. About Smart Data Solutions As a leader in the healthcare industry, Smart Data Solutions’ mission is to make the health care market more efficient by leveraging technology to provide effective, high-quality claims processing solutions. SDS is committed to providing an unparalleled level of customization and places great value on providing personalized service. SDS brings a comprehensive set of tools and processes to every opportunity, which is carefully configured to the individual needs of each customer. Smart Data Solutions has focused on creating innovative solutions specifically to meet the needs of the healthcare market. Today, more than 400 TPAs, PPOs, HMOs, hospitals, and insurance companies depend on SDS for automation of intake, data capture, and front-end workflows for health insurance and claim administration entities. Visit or contact us at 651.894.6400.


H.H.C Group, one of the country’s leading national health care cost containment companies, announced the addition of the Provider Network of America’s (PNOA) Group Health and Workers’ Comp networks to its list of network partners. The addition of PNOA is part of HHC’s strategy of providing more and deeper discounts for its self-insured clients’ group health out-of-network claims and for discounting Workers’ Comp health claims below fee schedule in fee schedule states/ securing discounts in non-fee schedule states. “PNOA is a strong, fast growing PPO network that will enable us to continue to fulfill our mission of finding more ways to minimize our clients’ expenditures for the healthcare services their employees and members utilize,” said H.H.C. Group’s President and CEO Dr. Bruce D. Roffe’.

“PNOA will compliment H.H.C. Group and the services they provide by adding our almost 600,000 providers to their national coverage at more than competitive rates”. - Mark Dyer, CEO

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NEWS About H.H.C. Group  H.H.C. Group is a leading national health insurance consulting company providing a wide range of cost containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. H.H.C. Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service. H.H.C. Group's services include Claim Negotiation, Claim Repricing, Surprise Bill Claim Resolution, Medicare Reference 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. Visit or contact Bob Serber at or 301963-0762 ext. 163.  About Provider Network of America (PNOA) PNOA is a directly contracted provider network that partners with hospitals, ancillary facilities, and providers nationwide. PNOA has built a robust national network and is growing at a rate of about 3,000 new providers every week. Medicare based reimbursements and other unique discount methodologies have separated PNOA from the pack in securing affordable healthcare for it’s members. The PNOA contracting team delivers results FAST by utilizing a proprietary network development process. Complimentary with the network comes an elite and aggressive custom network development piece that includes a provider nomination process and whitespace build out. Visit or contact Jeremy Ramsland at or 800-472-2636 ext. 3214.


Portland, OR – 6 Degrees Health is proud to announce its newest product offering, MediShield 2.0, an enhanced add-on service that provides legal support for possible balance bill escalations or litigation. MediShield 2.0 is a PEPM legal product designed to step in when a resolution cannot be reached during the balance bill negotiation process. MediShield is available in all 50 states, provides full legal representation of the member, does not require the claim to be in collections, and provides defense in litigation regardless of the amount of the balance bill (i.e., no balance bill is too small or large). It’s affordable legal representation with no thresholds. “Our new robust legal product is another step in our master plan to resolve balance bills by providing patients with access to nationwide independent legal counsel,



regardless of the amount of the bill, and without any thresholds whatsoever. We are confident that the new product will eliminate patient anxiety and uncertainty that often accompanies balance bills so that employees can focus on living healthy productive lives,” stated Bonita HatchettBodle, General Counsel, 6 Degrees Health. 6 Degrees Health knows that not every balance bill requires the help of costly legal counsel. The company built its business on partnering with providers to deliver equitable and transparent healthcare reimbursement. Unfortunately, some balance bill negotiations do need legal representation to gain an affordable solution for the employer. 6 Degrees Health recognized this need and designed MediShield 2.0 to provide that legal support and to complement their suite of referencebased pricing (RBP) solutions. For more information on MediShield, please contact Heath Potter, Chief Growth Officer, at heathpotter@6degreesghealth. com, (503) 640-9933 Ext. 1102, and (971) 762-1406 direct. About 6 Degrees Health 6 Degrees Health is built to bring equity and fairness back into the healthcare reimbursement equation. Industryleading MediVI technology supports our cost containment solutions with objective, transparent, and defensible data. 6 Degrees Health’s solutions include everything from provider market analyses, reasonable value claim reports, ad hoc claim negotiations, evergreening provider contracts, and referenced-based pricing. Our veteran cost containment team partners with health plans and their channel partners to deliver unparalleled cost containment results. Visit


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


Mike Ferguson SIIA Simpsonville, SC


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


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

Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA


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

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

*Also serves as Director

NOVEMBER 2021 57


Mark Stadler Chief Executive Officer AccessHope, LLC Irwindale, CA

Thomas Drake Sales and Marketing/Project Manager Agile Premium Finance Captive Specialist San Diego, CA

Enma Ralda Executive Assistant Alter-Net Medical Services, Inc. West Lake Hills, TX

Matthew Snyder President & CMO Equipoint Partners McKinney, TX

Marisa Dollins Executive Assistant Kroger Prescription Plans Lake Mary, FL



Nelson Griswold Chairman NextGen Benefits Network Brentwood, TN

Brooks Wildasin Chief Underwriter OutcomeRx Bethesda, MD

Ryan Sachtjen CoFounder & CEO ThreeFlow Chicago, IL


Sammie Mackey VP Employee Health and Benefits Alliance Coal LLC Tulsa, OK

Maggie Larson Owner Stone Mountain Pet Lodge Ham Lake, MN

SILVER CORPORATE MEMBERS Shane Giuliani VP of Marketing WithMe Health San Mateo, CA

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

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)

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