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Digging Deeper HOW TWO LAYERS OF CLOSER SCRUTINY IN SELF-INSURANCE CAN MAKE A SUBSTANTIAL DIFFERENCE IN IMPROVING OUTCOMES AND MANAGING COSTS
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TABLE OF CONTENTS
SEPTEMBER 2019 VOL 131
W W W. S I P C O N L I N E . N E T
Digging Deeper HOW TWO LAYERS OF CLOSER SCRUTINY IN SELF-INSURANCE CAN MAKE A SUBSTANTIAL DIFFERENCE IN IMPROVING OUTCOMES AND MANAGING COSTS By Bruce Shutan
THE DIGITAL FUTURE IS HERE
By Karrie Hyatt
ACA, HIPAA and Federal Health Benefit Mandates THE AFFORDABLE CARE ACT (ACA), THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND OTHER FEDERAL HEALTH BENEFIT MANDATES
30 BROKER/ADVISOR PERSPECTIVES INSIGHTS FOR AND ABOUT BROKERS/ADVISORS ACTIVE IN THE SELF-INSURANCE MARKETPLACE 38
RAND REPORT HIGHLIGHTS DISPARITIES IN HOSPITAL PRICING, QUALITY
NEWS FROM SIIA MEMBERS
REFERENCE-BASED PRICING: PITFALLS FOR A NEW ERA
The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688
Self-Insurer’s Publishing Corp.
PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary
Digging Deeper HOW TWO LAYERS OF CLOSER SCRUTINY IN SELF-INSURANCE CAN MAKE A SUBSTANTIAL DIFFERENCE IN IMPROVING OUTCOMES AND MANAGING COSTS
Written by Bruce Shutan
hereâ€™s no denying that closer scrutiny of clinical decisions and health benefit claims can save both lives and dollars. In short, the power of deeper examination is that it not only can prevent medical and financial catastrophes but also promote transparency and hold health care facilities accountable for the services they provide to self-insured employers.
MEDICAL SECOND OPINIONS One such strategy involves medical second opinions. Some proponents have gone as far to suggest they should become a mandatory part of self-insured health plans in certain instances. Others caution against thinking of this service primarily as a costcontainment tool or remedy for bad medicine. Whatever the case may be, second opinions are considered good medicine at a time when physicians struggle to stay abreast of all the latest treatments or protocols for serious or chronic medical conditions, says Tina Karas, VP of marketing for WorldCare International Inc.
Digging Deeper As many as 75% of the more than 25,000 medical second opinions her firm has offered over the past 26 years have involved a change in treatment, while 26% resulted in a new diagnosis. She describes the return on investment as ranging from 2:1 to 6:1, depending on changes in treatment or diagnosis. Leveraging different levels of clinical expertise can generate the most comprehensive view of any given medical condition for more accurate Todd Thames diagnoses, according to Todd Thames, M.D., regional medical director, senior staff physician with Grand Rounds, which provides second opinions as well as connects patients with local and remote specialty care.
“The old adage is medicine is an art as much as it is a science,” he observes, noting some change in diagnosis or treatment plan in 65% of cases that are run through a second-opinion service. An independent second opinion should be required for specified diagnoses and treatment plans given the propensity for misdiagnoses and medical errors, suggests Keith McNeil, co-founder of Arrow Benefits Group (ABG), which is part of the TRUE Network of Advisors. In fact, a large client of his will decide next month whether to pursue this avenue. “The number of errors in diagnosis and treatment plans is frightening,” he observes, while unnecessary surgeries in just orthopedics alone “is astounding.” While a big believer in second opinions, Thames cautions self-insured employers against making the service mandatory. By doing so, they risk a negative shift in the patient mindset to where it’s viewed as more of an obstacle, rather than an Jennifer Grubbs adjunct or augmentation, to care. For example, he says having to always endure an additional round of paperwork may further frustrate health plan members who are already predisposed to the system’s delays and economic burden. Several industry observers caution that the perception of second-guessing doctors is
“Not all cases we review, or even a preponderance of cases, involve any sort of misdiagnoses or medical errors,” says Jennifer Grubbs, independent medical review operations manager
for Mitchell MCN.
Part of the process simply helps determine if any information could be missing, she explains, while having a peer-to-peer call with the treating doctor helps gain a better understanding of the situation. Receiving an unbiased opinion helps self-insured health plans prevent unnecessary or costly procedures and demonstrates to patients that their needs are being addressed. Grubbs says this effort can help guard against escalating disputes and avoid costly appeals. The collaborative aspect is reflected in ABG’s recent partnership with MORE Health, a medical second opinion service it offers on behalf of employer clients to help those who face a serious, lifechanging illness. Mindful of the need for a speedy resolution, the service provider guarantees that it will respond within five business days of receiving relevant medical records. One key selling point of this service is that the vendor is more inclined to work alongside each doctor to come up with a combined diagnosis treatment plan that makes sense. “If for some reason those two simply cannot come to a meeting of the minds, they can even get another doctor in there who’s independent to give a third opinion, “ McNeil notes.
AN ORTHOPEDIC SURGEON’S VIEW Perhaps no one can appreciate the value of second opinions more than Ira Weintraub, M.D., chief medical officer for WellRithms, a leader in health care cost-containment reimbursement methodology and network replacement solutions for the self-funded market. An orthopedic surgeon for more than 40 years, he knows his specialty has
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Digging Deeper he says. Another conundrum involves patients wanting a tie-breaking view if the first two opinions differ. Without a doubt, Karas believes second opinions make sense for serious or deadly medical conditions such as cancer, cardiovascular conditions or rheumatoid arthritis and can help self-insured employers avoid unnecessary or costly treatments. Other areas where they may be considered particularly valuable include genetic testing, experimental and investigational services, and high-cost drugs, according to Grubbs.
Ira Weintraub come under fire for performing too many surgical procedures. He also has seen scores of unnecessary MRI and CT scans ordered through the years, as well as trips to the ER that could have been avoided. Total hip or knee replacements are “almost always very complex,” Weintraub notes, while complications may arise even after successful operations. He deems another pair of eyes in these cases worthwhile, though cautions that the additional scrutiny isn’t intended as a cost-containment tool.
Eagle eyes are perhaps best cast on high-stakes diagnoses involving extremely dangerous treatment options. “We’ve been amazingly successful in developing some really effective treatments against many cancers,” Thames says, “but they have significant side effects and are also expensive. So you want to make sure that you have an accurate diagnosis.” Close scrutiny of both the clinical and pathology aspects of care can serve as “a lynchpin towards making an accurate diagnosis,” he adds. Acute care episodes such as a broken bone or upper respiratory infection frequently don’t require second opinions because of the short-term and resolvable nature of these scenarios. But there could be issues hidden from view that may be worth another look. For example, “if the same person with a broken bone has a history of multiple other fractures there may be a more serious underlying cause such as bone cancer, which warrants a medical second opinion,” Karas explains. The same is true for an
“The problem with centers of excellence is they tend to jack up the prices because they think they're the best and they should get paid more than anybody else,” SEPTEMBER 2019
Digging Deeper even use residents. WorldCare also routinely rereads all radiology studies and pathology samples because they’re prone to error rates of between 10% and 30%. One related area that could benefit from second opinions is behavioral health. WorldCare recently completed a pilot program that applied mental health medical second opinions to long-term disability cases. The impact was significant, with 80% of claimants returning to work, a 70% change in diagnosis, 90% change in treatment plan and 100% participant satisfaction rating. Karas says it resulted in an average reserve release of $200,000 or $25,000 in annual discounted disability payments. Tina Karas
INDEPENDENT BILL REVIEW
upper respiratory infection that lingers or recurs, which she says could be a chronic pulmonary issue such as asthma or chronic obstructive pulmonary disease, both of which would warrant a closer look.
Another popular method for at least putting a lid on soaring health care costs involves independent medical bill review. A comprehensive approach is essential for spotting abusive billing practices at a time when medical bills are rising at unprecedented levels, according to Weintraub, who also stresses the importance of contracting with providers at fair rates. In addition, he says that understanding medicine gives him a leg up in all bill reviews.
Two medical procedures that stand to benefit most from greater scrutiny are back surgeries and joint replacements, both of which Thames believes are overdone and costly. He also notes that “the five-year outcomes from many back surgeries are not that good,” citing the potential for complications down the road.
His firm uses a proprietary approach to identify any incorrectly entered medical diagnostic codes and edits or what he labels “shenanigans” to up-code surgeries. “Coding has become a game,” he laments, recalling several experiences with this widespread unscrupulous practice.
Clinical rigor is hugely important when it comes to procuring second opinions. As the only institution-based medical second opinion provider, WorldCare has the luxury of deploying multi-disciplinary teams of leading specialists and subspecialists at top-ranked U.S. hospitals.
“On average we have four physicians involved in each medical second opinion,” Karas reports. Others simply have one physician they select from a Rolodex to review their cases, she adds, and sometimes they
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Digging Deeper After reviewing the medical records, X-rays and operating notes of a patient’s spine surgery, for example, Weintraub found that as many as eight of 14 codes weren’t possible and just half a dozen ended up being paid. In another case involving a total knee replacement, the patient was charged for two prostheses, rods and screws. But charging for a second prosthesis is verboten, he explains, surmising that the patient’s leg more than likely was broken during the surgery and, therefore, required another-size prosthesis. The hospital has to eat the cost of a second prosthesis, he says.
A FORENSIC APPROACH TO RECOVERING FUNDS With a growing emphasis on algorithms and health care analytics, some emerging industry solutions are tearing a page from the CSI TV show playbook to sell their value proposition. “We are forensically analyzing medical claims to maximize payment integrity systems,” says Jeff Borglin, a health care strategist and partner with Iron Sky Advisors. Whereas medical claim audits involve a sampling of health plan data, a specialty vendor whose service he offers employer clients actually reviews 100% of all claims about half a dozen levels deep. This forensic hunt checks improperly billed payments against rule sets provided by the National Correct Coding Initiative, Medicare and Medicaid. The next phase is to recover those payments. “We want to bring to the marketplace truth and accountability,” explains Borglin, describing the effort as “a post-payment forensic claim review and recovery program” that differs from scores of prepayment systems already in place. “Every administrator of a self-funded plan has a fiduciary responsibility under ERISA to manage that plan to the best of their ability.” But not having a complete set of medical claims data can only lead to trouble. One valuable resource for bill reviews involves the National Association of Independent Review Organizations, which Grubbs says develops guidelines for solving common industry problems and promotes standards for medical reviews. Founded in 2001, the nonprofit group has demonstrated the value of Utilization Review Accreditation Commission (URAC) accreditation and their processes for IRO. Her firm of Mitchell MCN is a URAC-accredited IRO that works with providers in more than 90 medical specialties. The company compares appropriate vs. erroneous billing or coding errors against claims trends. Other services include independent provider audits for a holistic view of billing history and inter-rater reliability system to detect outliers. The trouble with some health care analytics vendors is when financial reports from their population health system don’t square with numbers that the third-party administrator provides, explains Mark Combs, founder and CEO of Self Insured Reporting.
Mark Combs In a nutshell, he says any data discrepancies from highly segmented information simply fail to reveal
“a comprehensive view of the total costs to a selfinsured employer, which is what the CFO is interested in… Having a common data source is critical because when certain parties only have certain things, and then they start trying to communicate with one another, it just doesn’t work.” Combs pulls together raw data from disparate sources into a single Excel spreadsheet that includes not only medical claims, but also benefits eligibility, administrative fees, reinsurance and stop-loss reimbursements, projected renewals and other key variables.
Digging Deeper One cause of inflated hospital charges is that many providers are pushing back on reference-based pricing agreements that peg their compensation to a percentage of Medicare, which Weintraub says is “just an arbitrary number” that wouldn’t stand up in court on a billing dispute. That’s why WellRithms employs methodologies associated with the legal principle of quantum meruit in re-pricing medical services. The Latin
“a reasonable sum of money to be paid for services rendered or work done when the amount due is not stipulated in a legally enforceable contract.” term means
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The Digital Future
uring the last few years, there has been heavy investment in insurtech companies that are developing digital tools for the insurance sector. Previously, only large insurance companies, with a lot of capital outlay, were able to access advanced digital tools, but with rapidly developing digital technology created for insurers, captives in the small and medium range can access these digital tools through thirdparty providers.
Written by Karrie Hyatt
With access to digital tools through tech companies, captives will be able to reach more efficient levels of operation and provide top-notch quality services to their owners or members. More advanced digital tools will also allow captives, already known to be nimble, to use their resources to create better programs and products for their owners.
IMPROVING THROUGH DIGITAL TOOLS The key tool in any digital toolbox is providing reliable data, as well as easy access to that data. This is especially for financial companies. Insurtech developers are helping all types of captives to find the right tools in order to have the best tech to meet this important need.
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Digital Future Digital tools come in the form of cloud-based data storage, robotic process automation (RPA), application programming interface (API), the Internet of Things, and even artificial intelligence (AI). These tools help to improve risk management, comprehensive reporting, and data aggregation. These tools can also apply to mobile technology that streamlines loss control. These technologies and platforms increase workflow and improve risk analysis for captive insurers.
computers and mobile phones, captives can become even more responsive to their owners. Creating ease of access for members to retrieve their policy information, captives can reduce operating expenses while providing better service their members.
According to Tim Cuckow, vice president of sales with CHSI, a provider of insurance and risk management software, “Group captives strive to provide the highest level of service to their members so, similar to the single parent captive, they value risk management technology. However, they also are greatly interested in memberfacing tools, i.e., web portals to provide members multiple points of engagement.”
“Captives are innovative by their very nature,” said Cuckow, “So we are constantly engaged in discussions with clients and prospective clients about ways to leverage ours and others’ technology to provide the greatest level of service to the captive’s stakeholders.”
The multiple points of engagement that Cuckow mentions is a way to interact with captive members through real-time access to essential information. By offering brokers and members quick access to information—such as instant rate quotes, the ability to promptly file a claim, to check a claim status, or to review policies—through
Providing state-of-the-art service to customers, clients, owners, or members is key to any company right now. According to a recent survey published by the digital customer relationship management tech company, Salesforce, 80% of their customers say, “that the experience a company provides is as important as its products and services.” This rings true especially for a company where the customer is also an owner. Captives have to be increasingly sensitive to the quick access to information their owners want and need.
As leaders in new ways to self-insure, many captives bring their ideas to their digital providers in order to customize their digital platforms to their needs.
Digital Future For example, there has been a great deal of discussion recently surrounding the integration of smaller, niche cloudtechnology products into the enterprisewide platforms (like CHSI’s Connections) so as to create something of a ‘nextgeneration’ platform which integrates best-of-breed cloud-based technologies.” However, Matthew R. Blackley, the chief technology officer at Maple Technologies, has found that not all captives he’s worked with are so forward-facing where technology is concerned. “Maple Technologies is one of the oldest, longstanding core system solution providers in the market, and we have worked closely with the captive industry for nearly twenty years. We’ve found it to be really a mixed bag when it comes to clients bringing us ideas. Some that
are tech-savvy do and have a good understanding of how the tech works and, more importantly, will work for them. Others come with an end goal and rely on us to define a tech path or approach to embrace and build the desired solution.”
consistency,” said Cuckow. “Some captives and captive managers still rely on spreadsheets which can be unreliable, unwieldy, and unprotected. Although a wonderful tool, spreadsheets have limited capabilities and sometimes can be the cause of significant data errors. Moving to modern platform greatly reduces this risk.”
While captives seem to be adopting digital platforms at a quicker pace than other sectors of the insurance industry, there is still some areas where they are dropping the ball and it’s in the most fundamental part of any digital platform— reliable data.
FUTURE OF DIGITAL
“If there is any concern, we are seeing some lag in adapting to the paradigm shift relating to data security and data
While it’s no secret that the insurance industry has been slow to adopt new technology and more modern efficiencies, times are changing. “By and large, the insurance industry has long ignored investments in technologies which will provide flexibility and
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Digital Future choice in the delivery of products, billing/payments, and more,” said Blackley. “The captives sector is certainly no exception. This leaves lots of room for improvement.” And improvements, in the form of new tech ideas, are coming along quickly.
In coming years, Blackley sees API, or application programming interface, as an important way for captives to access digital tools. API is a software intermediary that allows two applications to talk to each other. Mobile phone apps are API’s, allowing you to interact with a website through a different medium. API’s also add a level of security.
To use the mobile phone example again, the data on your phone is never directly exposed to the website’s server, which keeps it safe. According to Blackley, “Third party niche data services offered through API interfaces will be a key springboard for captives and their utilization of tech. It will reduce cost substantially, making the tech more affordable and, from our vantage point, integrating API is a fairly straightforward low-cost process. In combination this will afford captives the ability to compete for business more effectively.”
Two upcoming technologies that are much anticipated in the captive marketplace are artificial intelligence (AI) and blockchain ledger technology. While blockchain seems to make the news more often, industry insiders are really looking towards the applications of AI.
According to Cuckow, “We are watching with great anticipation how artificial intelligence will impact the industry. More and more the technology is ‘popping up,’ however some maturation is in order first. There has been some significant strides made on the health and life side (with some unintended consequences), so watching how that plays out and then understanding the potential impact on the commercial side will be interesting. Exciting times!”
AI will completely change how insurance companies handle claims, distribution, and underwriting. Potentialities of AI include policies priced on behavior— such as for auto insurance and health insurance; personalized customer service and user experiences; and customized claim settlements that are faster and more efficient. As it expands, AI technology will relieve the human component from labor intensive, repetitive work leaving employees to do more complex functions and provide higher quality service.
Blockchain technology is already being explored by insurtech companies, insurers, and now state regulatory bodies. Blockchain technology, often described as a distributed digital ledger, records and stores data in chronologically ordered blocks across devices on a distributed network of nodes.
This makes blockchain resistant to hacking and to technical failures. Once blocks are logged and confirmed, it is difficult to remove or change an entry, which is why blockchain is a secure and
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Digital Future stable record of financial transactions. To interface with blockchain tech, API’s are used to facilitate their use across multiple entities.
For captives, blockchain can reduce or eliminate manual processes by automating the work. This will transform employee’s workflow practices and will help captives complete regulatory filings more efficiently.
Insurtech companies are already producing blockchain tech aimed at the financial, insurance, and captive markets. In Vermont and Washington, D.C., regulators are also experimenting with the technology in their record maintenance processes to make filings more efficient for the companies they regulate.
The insurtech space has been growing exponentially over the last several years, making it now a billion-dollar industry. As fast as new tech becomes available, it can be hard for captives to keep up with the changing technology landscape which can make them less competitive in the marketplace. According to Blackley, “The phrase ‘adapt or die’ comes to mind here. If captives aren’t willing to be at least as innovative as their competitors, they will either have to look at making an acquisition, becoming an acquisition, or going out of business.”
For those captives feeling left behind amidst the expanding world of insurtech,
“I would encourage those working with and/or for captives to take time and learn more from the vendors affiliated with the market. Whether that be at conferences, online, or through in-person meetings, learn about new technologies and how they could impact your organization. Vendors in this space are sophisticated and knowledgeable about the challenges captives face and the impact technology would have on those challenges. Take a couple of minutes and tour the exhibit hall at the next captive conference you attend, you won’t be disappointed!” Cuckow has some advice.
Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:
Q & A &
he Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Womenâ€™s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates.
Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, and Dan Taylor provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley Gillihan, Carolyn Smith and Dan Taylor are members of the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questionerâ€™s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at email@example.com.
A NEW ERA OF HRAS BEGINS IN 2020 After a little more than 18 months after the President’s Executive Order, the Departments of Labor, Treasury, and Health and Human Services (the “triagencies”) have issued their long-awaited final regulations on health reimbursement arrangements (HRAs). The final regulations come a mere eight months after the triagencies issued proposed HRA regulations in response to the Executive Order. Like the proposed regulations, these final regulations expand HRAs in ways that could significantly change the health benefits landscape (especially for small employers) by establishing two new HRAs:
• An HRA that is integrated with certain individual market coverage (IMC) •
and Medicare (individual coverage HRA (ICHRA)). A nonintegrated general purpose HRA that is considered an excepted benefit (excepted benefit HRA (EBHRA)).
The final regulations are effective for plan years beginning on or after January 1, 2020. These new designs should, subject to the availability of traditional individual health insurance coverage, significantly expand the possibilities for defined contribution health coverage—igniting a new HRA-Era beginning in 2020. We address this new guidance in a two-part series. This article addresses the ICHRA. Next month’s article will address the EBHRA.
INTRODUCTION What prompted the regulations? Before the Affordable Care Act (ACA), it was not uncommon for employers to offer HRAs as the sole group health coverage offered by employers to employees, and such HRAs frequently reimbursed an employee’s premiums for major medical coverage purchased in the individual market. The ACA changed that. After the ACA became effective, HRAs offered to active employees generally had to be integrated with group health coverage and meet certain other requirements (such as allowing the employee to waive coverage each year). Why?
The integration requirements are driven largely by a health reform requirement added by the ACA—Public Health Service Act (PHSA) Section 2711. PHSA Section 2711 prohibits group health plans that provide other than excepted benefits from imposing annual or lifetime dollar limits on essential health benefits. HRAs that reimbursed general medical expenses (i.e., other than dental or vision) provide essential health benefits.
Since an HRA limits the reimbursement each year to a specified amount, a general purpose HRA would, by its nature, run afoul of the Section 2711 prohibition. Tri-agency guidance made it clear that HRAs could only be integrated with a group health plan other than an HRA and plans providing only excepted benefits. The tri-agency guidance also impacted HRAs that reimbursed an employee’s individual market coverage (IMC) premiums. IMC, by law, had to provide essential health benefits. Since a premium reimbursement HRA paid or reimbursed the premiums for IMC coverage, the tri-agency guidance deemed the HRA to run afoul of the prohibition in Section 2711.
Practice Pointer: Nonintegrated HRAs would also run afoul of PHSA Section 2713—the requirement to provide coverage for recommended preventive treatment services, as defined by the ACA. SEPTEMBER 2019
Congress expands access to HRAs with QSEHRAs—sort of! In 2016, Congress took an initial step to expand the scope of HRAs by creating a new type of HRA, the QSEHRA. QSEHRAs allow small employers to integrate an HRA with IMC under certain circumstances. QSEHRAs only go so far. First and foremost, they are limited to employers that average fewer than 50 full-time equivalents in the prior calendar year. In other words, QSEHRAs are only available to employers that are not applicable large employers as defined for purposes of the ACA employer shared responsibility rules. Second, the reimbursement is limited each year (adjusted annually by the IRS based on inflation). Third, an employer cannot not offer any other health coverage (even vision, dental, or excepted benefits) for any other employees and also offer a QSEHRA. Finally, the requirements for establishing and maintaining a QSEHRA are very complex. How do the final regulations expand access to HRAs? Effective for plan years beginning on or after January 1, 2020, the final regulations allow HRAs sponsored by employers of all sizes to be integrated with IMC (ICHRAs) and to offer excepted benefit HRAs (EBHRAs) to employees who are eligible for traditional major medical coverage.
ICHRA What is an ICHRA? HRAs sponsored by employers of any size may be integrated with IMC for purposes of PHSA Section 2711 if the following requirements are satisfied:
• The HRA is limited to employees and their spouse or tax dependents who are enrolled in IMC that qualifies as ACA-compliant coverage—i.e., coverage that satisfies PHSA 2711 (relating to the prohibition on annual and lifetime caps for EHBs) and 2713 (relating to mandatory preventive care benefits)— or Medicare (“qualifying IMC”) for each month that they are covered by the HRA. For example, ACA-compliant catastrophic coverage and coverage subject to an ACA 1332 state waiver, as well as so-called grandmothered and grandfathered plan coverage, would constitute qualifying IMC. Certain insured individual coverage student plans may also constitute qualifying IMC. Group health coverage of any type (including a spouse’s plan) and exceptedbenefit-only coverage would not constitute qualifying IMC. Also, short-term limited-duration insurance (STLDI) coverage and health care sharing ministry coverages do not constitute qualifying IMC.
• The employer must obtain substantiation from the employee that the employee and any covered family members have qualifying IMC both initially and thereafter each time expenses are submitted for reimbursement. The regulations indicate that employee attestation of qualifying IMC is sufficient unless the employer has knowledge to the contrary. The regulations include a model form for participant attestation.
• An employee or dependent who ceases to be covered by qualifying IMC would forfeit any remaining balance in the HRA subject to any applicable continuation rules. COBRA eligibility could arise in the case of traditional COBRA events such as termination of employment or reduction in hours (and presumably death, divorce, or loss of dependent status under the IMC).
• The employer must offer the ICHRA on the same terms and conditions to all eligible employees within a “designated” class. Variations to benefits offered to employees within the designated class can only be based on family size and age. Age-based variations in ICHRA benefits cannot exceed the 3:1 ratio allowed for individual market premium differences based on age. If coverage is provided to one or more former employees, it must be provided on the same terms
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and conditions as provided to the class of employees the employee formerly belonged to and cannot vary based on compensation or years of service. Finally, ICHRA coverage can be pro-rated based on period of participation in the plan year.
Practice Pointer Wellness Programs: The final regulations clarify that an employer must offer the ICHRA on the same terms and conditions to all eligible employees within a “designated” class. It is unclear whether this would prohibit ICHRAs funded in part by disparate wellness program contributions. Read literally, this could be a problem. Practice Pointer HSAs: The final regulations clarify that an employer might offer employees within a class an option of ICHRA coverage that is limited to IMC premium expenses (and thus is HSA compatible) or IMC expenses and other nonexcepted Section 213(d) expenses (which would disqualify an electing employee from HSA eligibility) without violating the “same terms and conditions” requirement. • The designated classes are determined on a common-law employer basis and not on a controlled-group basis. This means that different employers within a controlled group may (subject to the class size rules) have different class rules. In addition, the final rules allow the class determination to apply to employees hired after a specified date (e.g., allowing the new ICHRA benefit to be extended prospectively while current employees retain eligibility under a traditional group health plan). The classes identified in the regulations are:
o Salaried. o Non-salaried (e.g., hourly). o Full-time (as defined by Section 105 or 4980H). o Part-time (as defined by Section 105 or 4980H). 24
o Seasonal (as defined by Section 105 or 4980H).
o Employees in a unit
covered by a particular collective bargaining agreement.
o Employees who have
not satisfied a waiting period for coverage.
o Nonresident aliens with no U.S.-based income.
o Employees of an
entity that hired the employees for temporary placement at another entity (temporary-worker rule).
o Employees whose
primary site of employment is in the same rating area. The rating area is defined as the rating area used for ACA premium rating requirements in the individual market. This will essentially allow employers to offer or vary the benefits based on worksite location.
o Any combination of
two or more of the above classes. For example, full-time union employees could be a designated class separate and apart from any other designated class.
Certain class types that are offered an ICHRA are subject to a minimum size requirement if the employer also offers a traditional plan to one or more classes of employees. The minimum class size is determined before the plan year based on the number of employees the employer reasonably expects to employ on the first day of the plan year: 10 for an employer with fewer than 100 employees, or 10% of the total number of employees for an employer with 100 to 200 employees, and 20 thereafter. The class categories subject to this minimum size requirement are salaried, non-salaried, full-time, part-time, and employees in the same rating area.
Practice Pointer: An ICHRA is a self-funded medical reimbursement plan subject to Section 105, including the Section 105(h) nondiscrimination requirements. Offering different benefits to different classes of employees could run afoul of the Section 105(h) nondiscrimination rules. Likewise, offering different benefits based on age could run afoul of the nondiscrimination rules. Since the regulations allow variations between the designated classes and within a class based on age, the IRS has indicated that future guidance is likely to exempt these differences from the Section 105(h) rules so long as the ICHRA satisfies the ICHRA requirements.. • If employees are offered the ICHRA, the employer cannot also offer those employees traditional group health plan coverage that provides other than excepted benefits. An employer plan sponsor may offer the same employees both an ICHRA and excepted benefits such as vision, dental, health FSA, or fixed indemnity coverage.
Practice Pointer FSA/ICHRA Combo Cleared: A health FSA will not qualify as an excepted benefit unless, among other things, the FSA-eligible employee is also offered the opportunity to enroll in group health plan coverage that provides other than excepted benefits. Since an ICHRA is a group health plan that provides other than excepted benefits, a health FSA offered alongside an ICHRA may still qualify as an excepted benefit.
• Employees must be allowed to opt out and waive benefits at least annually and upon termination (subject to COBRA requirements). The final regulations clarify that an optout by an employee would be considered a waiver for eligible dependents as well.
• The employer must provide an annual notice to employees at least 90 days before the start of each plan year or before the effective date of coverage (if the employee becomes eligible after the start of the plan year). An extended notice period is allowed for the first plan year, and the agencies have provided a model notice for these purposes.
How do the final regulations align the ICHRA rules with Medicare’s rules?
The preamble describes a struggle between the application of Medicare’s anti-duplication and secondary payer rules and the proposed regulations regarding ICHRAs, which did not specifically address an HRA’s integration with Medicare—even though the triagencies had addressed integration with Medicare in the HRA provisions of the prior final regulations and IRS Notice 2015-17. Medicare’s anti-duplication rules prohibit the sale of IMC to an individual enrolled in Medicare. This meant that Medicare-eligible employees in a class of employees offered the ICHRA could not participate since they could not purchase
IMC—making the ICHRA unavailable to all employees in the class on the same terms and conditions. Also, Medicare’s secondary payer (MSP) rules prohibit employers subject to the MSP rules from offering incentives. The final regulations make the following very important clarifications:
• An employer subject to MSP rules may offer an ICHRA to a class of employees without running afoul of those rules, even though some employees in the class are eligible for or enrolled in Medicare. At first glance, this seems counterintuitive since no member of that class may also be offered traditional health coverage—an apparent MSP violation—but the triagencies noted that the HRA itself is a group health plan. Consequently, such employees are, in fact, offered group health plan coverage on the same terms as other non-Medicare-eligible employees in the same class—consistent with the MSP rules. Likewise, reimbursement of Medicare premiums and/or Medicare supplemental premiums by the ICHRA is not considered an impermissible financial incentive to forgo enrollment in the employer’s group health plan since such employees are, in fact, enrolled in the employer’s group health plan.
• For employers subject to the MSP rules, the ICHRA may not limit reimbursement of medical expenses to expenses not otherwise covered by Medicare; however, the ICHRA may be limited to premiums or medical expenses generally.
• To align the rules that the ICHRA be offered on the same terms and conditions to all members of the eligible class and Medicare’s antiduplication rules, which prohibit the sale of IMC to a Medicare beneficiary, the final regulations treat Medicare as qualifying IMC.
Thus, employees must be allowed to qualify for the ICHRA by enrolling in either ACAcompliant IMC or Medicare. This applies without regard to whether the employer is subject to the MSP rules, since the anti-duplication rules apply irrespective of the MSP rules.
What is the maximum reimbursement for an ICHRA? There is no regulatory prescribed maximum reimbursement for an ICHRA. Also, unused amounts may carry over from year to year without limitation.
What expenses are reimbursable from an ICHRA? Except as may otherwise be limited by plan design, ICHRAs may reimburse any expense that qualifies as “medical care” under Section 213(d).
Does ERISA apply to the ICHRA? The DOL issued separate regulations indicating that ERISA applies to the HRA part of the ICHRA and that ERISA will also apply to the policies the ICHRA is integrated with unless the employer otherwise satisfies ERISA’s voluntary plan safe harbor (except, of course, the prohibition against employer contributions). This means that employers must not receive any consideration in connection with the ICHRA (such as free or subsidized FSA or HRA administration). However, as with HSAs, we would anticipate that any employer FICA tax savings from an ICHRA supplemental cafeteria plan (see below) would not be considered to be impermissible remuneration. The DOL further notes that sponsors of an ICHRA should be careful not to endorse any particular carrier or coverage, including by offering a limited subset of IMC through a “private exchange.” It would seem that employers must accept all forms of IMC selected by employees to limit exposure under the non-endorsement rule.
Can ICHRA participants pay the excess IMC premiums with pre-tax salary reductions? In a surprising twist, the regulations indicate that employees may pay the portion of the IMC premiums not paid for by the ICHRA with pre-tax salary reductions through a “supplemental” cafeteria plan maintained by the employer. Presumably this supplemental plan provision need not be part of a separate plan and could be part of an existing cafeteria plan.
The supplemental cafeteria plan must be extended to all employees within a class and would only be available for qualifying IMC purchased outside the Exchange. This would apparently include Exchangeeligible coverage that is purchased off the Exchange. Such an arrangement would not be considered traditional group health coverage disqualifying the individual from participating in an ICHRA.
Can “applicable large employers” use an ICHRA to avoid employer shared responsibility excise taxes? Yes, they possibly can. The proposed regulations and subsequent guidance issued by the IRS (see Notice 201888) address the application of the employer shared responsibility rules to an ICHRA. The final regulations note that additional proposed rules will be issued to incorporate IRS Notice 2018-88 and the comments received relating to it. In the interim:
• The ICHRA qualifies as minimum essential coverage (MEC); therefore, an employer that offers an ICHRA (or a combination of group major medical coverage and ICHRA coverage) to at least 95% of its full-time employees in a month will avoid the excise tax under Section 4980H(a) (aka the “sledgehammer” tax) for that month.
• An applicable large employer can also avoid the Section 4980H(b) tax (aka the “tackhammer” tax) if the ICHRA coverage is affordable. If the coverage is affordable, it will also be considered to provide minimum value. The IRS has prescribed the following special rules to facilitate the employer’s affordability calculation:
o The rating area used
by the employer may be the rating area for the employee’s primary situs of employment. o Employers may determine affordability for a year using the silver plan premiums from the prior calendar year or, if the plan year spans two calendar years, the premiums for the first month of the plan year, even if the silver plan premiums change during the plan year. o The IRS has indicated that employers may continue to use the Section 4980H affordability safe harbors to determine whether the ICHRA is “affordable” and provides minimum value for purposes of Section 4980H.
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INSIGHTS FOR AND ABOUT BROKERS/ADVISORS ACTIVE IN THE SELF-INSURANCE MARKETPLACE
hy Agencies Fail When Hiring Insurance Producers
Being a business owner is not for the faint of heart. The number of critical decisions to be made every day is exhausting.
Written by Kevin Trokey
• Are we meeting the needs of our clients? • Are we even sure what those needs are? • Where is our next competitor coming from? • How can we protect our profit margin? • Who do we need to be in 24 months? • Of course, this list could go on and on and on and . . .
However, there is one question that I just don’t see insurance agency owners taking seriously enough: How do I ensure the success of the salesperson I am about to hire?
EVERYTHING IS ON THE LINE Of course, every new hire (in any position) is a decision to be taken seriously, but the decision of a producer is a little more critical. This is a highly compensated position with a lot of financial risk for the agency. The agency depends on this position to bring in new revenue and, at the same time, also depends on this position to help retain revenue. And, however this producer operates in the market impacts the very brand/reputation of the agency.
Sadly, while the decision as to whom to hire to fill this position should be the most scrutinized in an agency, way too many agency owners take the “let’s just see what sticks” mentality. Or, at the very least, they don’t do everything possible to ensure the highest likelihood of success.
Even in an ideal situation where everything is done the way it needs to be done, making a successful producer hire is challenging. But, when done the way it is typically done in this industry, successful producer hires are all but impossible.
Ensuring the success of a new hire is one of the greatest responsibilities of any business owner.
HISTORY REPEATS ITSELF – BUT DOESN’T HAVE TO
I see agency owners making the same hiring mistakes over and over again. And, by this, I mean the same mistakes happen in agency after agency and also, within each agency, they keep making the same mistakes over and over.
I was coaching an agency owner who was somewhat angry that their young producer who had been on board for not quite a year wasn’t producing. The owner explained how sure he had been that this young woman would be successful. In this candidate, he saw a boldness and a willingness to take risk that he admired. She had fairly spontaneously made the decision to upset the apple cart of her life in pursuit of a personal ambition. Now she needed a “professional ambition” to balance the decision.
There is too much on the line for both sides to not do everything you can to ensure the relationship will be successful. The producer is committing their career, and a significant part of their personal life, to the agency. At the same time, the agency is putting resources, reputation, internal confidence, and growth opportunities on the line.
SEEK TO UNDERSTAND
I always ask lots of questions before I start giving advice. I asked the owner to explain a few things.
• Did she have insurance experience? No
• Did she have sales experience?
And, maybe surprising to you, those didn’t really bother me; it was these last two that did.
• How well did she test as compatible for the role? We didn’t test her • Tell me how you trained her once she started.
Um, we didn’t
Now this owner had already recognized the need to change their ways (which is why we were talking), and they were already significantly more successful at producer hires than the typical agency. But it’s easy to get distracted by a “good opportunity.”
• Did she have a network of connections? No
As an agency owner, you can get angry at young producers all you want, but most of the factors that will determine their success are within your control as the employer.
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4 MISSTEPS AGENCIES MAKE AS THEY RECRUIT/INTERVIEW
IT DOESN’T END WITH THE
• They are looking for the wrong traits. Instead of looking for someone who has a great “network of connections”, they should be looking for someone with a great level of intellectual curiosity.
• They don’t know how to interview. All too often we have sales people doing the interviewing, as agency owners are typically sales people themselves. What a horrifically bad idea! The interviewer ends up talking 90% of the time and leaves feeling good about the conversation, but not having learned anything meaningful about the candidate.
• No testing. I don’t just mean personality profile testing (which is critical); I also mean a way to test their ability to think critically and handle themselves in a sales situation (think role play and case studies).
Read back through these four missteps (no, seriously, read them again) and tell me it isn’t a miracle that an agency ever gets a quality hire to their first day of employment. Of course, at this point, even with a quality hire you have only gotten them to the starting line.
Believe it or not, in most agencies a newhire producer is tripped right out of the starting blocks. After all, it’s what happens, or doesn’t happen, after that first day that will ultimately determine success.
• A “we’re different” bias. This industry is notorious for re-churning the same batch of questionable candidates. Chances are most candidates have already worked at, and failed at, other agencies and/or with insurance carriers. Agencies ignore the failed history of their candidates, somehow believing that history won’t repeat itself. If the candidate hasn’t found success in the same role somewhere else, there’s a pretty good chance they won’t find it with you, especially if you are making the first three missteps above.
Here is what the new producer can look forward to once on board in a typical agency scenario.
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• No onboarding process • No training program • No ongoing coaching/mentoring
If you will take the time to build (or adopt) a sales process that focuses on your ability to make your clients more successful at what they do and assists them in making better buying decisions, you will have the necessary foundation for agency and producer success. If you won’t put forth that effort, then I suggest you don’t try to hire another producer. It’s not fair to them and it’s not fair to the rest of your team.
• No sales goals (at least with accountability/consequences)
• No accountability for behaviors
DON’T BE A FOOL
• No sales process • Wrong compensation model • Horrible sales meetings, if there are any
• No sales leadership
An effective, well-defined sales process will provide the litmus test you need to attract and properly evaluate a candidate. It will help ensure the success of that producer once on board. It will ensure you meet the increasingly complex needs of your clients. It will allow you to successfully address the items in my “once on board” checklist above. It will become the foundation of your agency.
• No market differentiation • Lack of ongoing education • Won’t be fired even when it is in everyone’s best interest
Successfully hiring insurance producers is never going to be foolproof, but it doesn’t need to be as hard as we make it. Those who have and effectively use a sales process are moving as close to foolproof as possible. Those who ignore the need for a sales process, well, they are simply providing proof of fools.
WHAT SALES PROCESS?
If there is a single common denominator woven into all of these missteps, it’s the lack of a formal sales process. A vast majority of the agencies we talk to have no formal sales process. Providing quotes at renewal is NOT a sales process; it’s an increasingly commoditized, automated, transactional, and decreasingly valued part of what brokers do for their clients.
Without a sales process, how can you evaluate a candidate as a fit? How do you train them? How do you coach them? How can you ensure their success? How do you protect your financial investment? How can you protect the very brand of your own agency?!
Kevin Trokey is the Founding Partner of Q4intelligence, a marketing and sales enablement firm committed to the preservation and transformation of the independent agency system. He writes prolifically regarding the many challenges being faced by today’s agencies, providing guidance to overcome those challenges. He is a frequent industry speaker and was recognized by the National Association of Health Underwriters as their speaker of the year in 2016.
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REFERENCE-BASED PRICING: PITFALLS FOR A NEW ERA
ow many times have you read an article or listened to a sales pitch about how great reference-based pricing is? RBP can add a lot of value, and many of us have seen that first-hand. But that is not the purpose of this article. As a consultant in the self-funded industry, The Phia Group has lots of opportunities to review and assess reference-based pricing plans and various claims situations. We have seen plans experience a great deal of RBP success – but we have also seen many RBP failures. As many of you reading this have found out the hard way, and often unexpectedly, there are certain ways that RBP can go poorly and cause harm to an employer’s health plan, employee base, or even business reputation.
Written by Jon Jablon
38 THE SELF-INSURER
RBP is a powerful payment methodology used by thousands of health plans around the country, but like so many cost-containment tools, a full understanding of the entire process and a strong implementation of the key elements are absolutely crucial to its success – and even seemingly inconsequential flaws in the process can prove to be problematic down the road. Let’s go through some of the biggest pitfalls.
LACK OF PREPARATION: POOR SUPPORTING SPD LANGUAGE
Like so many things in the self-funded industry, a health plan’s rights with respect to RBP pricing are only as good as the plan’s language. A plan document should contain language to both allow the plan to pay claims as it sees fit, and to create arguments against balancebilling. A lack of adequate plan language makes the health plan especially vulnerable to appeals and lawsuits. To provide a practical example, I was recently presented with a case where a health plan had neglected its Plan Document through the years. It was last restated in the late ‘90s, it had over 30 amendments, and it was just plain old confusing to read. That group utilized an RBP methodology, and yet there was a complete lack of payment limitation language, except for one sentence: “Expenses allowed at an amount the Supervisor deems reasonable.”
155% of Medicare at which rate the group’s RBP vendor had been pricing claims for six months. What happened next? A large hospital system decided that it wanted to appeal, rather than jumping straight to balance-billing, and in the course of the appeal, the Plan Document was produced. I can just imagine the hospital’s attorney’s eyes filling with gigantic dollar signs when it saw that non-existent RBP language; the result is that while the vendor was repricing claims and raking in its fee, the Plan Document had not supported the program, and the Plan had not limited its exposure. Rather than face a lawsuit, the Plan had no choice but to pay the hospital’s demand in full… and hopefully amend its Plan Document language as soon as possible. The seldom-referenced section 402(b)(4) of ERISA requires a health plan to “specify the basis on which payments are made to and from the plan.” There is precious little law to interpret exactly what that means, but it is the backbone of the sentiment that “your rights are only as good as your language,” and it seems safe to say that the particular provision within this health plan does not meet the relatively low standard of specifying how payments are made.
There are two main problems there: one is that the Supervisor was the TPA (so the first moral of this story is that TPAs should be wary of that type of unexpected liability), and the other is that this does not reference the
POOR EXPLANATIONS: INACCURATE EOBS
There are two extremely common mistakes that health plans make when generating Explanations of Benefits with respect to RBP claims: (1) providing inaccurate or nonspecific remark codes, and (2) calling the amount over the Plan’s allowable amount a “discount.” The former is a compliance problem; ERISA requires that EOBs contain not only an explanation of why the claim was priced as it was (according to the regulations at 29 CFR 2560-503.1, “The specific reason or reasons for the adverse determination”), but also a reference to the specific provision in the Plan Document that allows the denial (“Reference to the specific plan provisions on which the determination is based”).
RBP results can be so good that some employers are tempted to apply RBP to contracted claims as well, the theory being that the contracted rate is still higher than what the plan deems reasonable, so the RBP savings are desirable for all claims, even contracted ones. While the contracted rate may well be just as arbitrary and overbilled as the original billed charges, it’s important to remember that contracts are legally-binding instruments, and contracted providers sometimes have powerful legal backing. This is perhaps another topic for another article – suffice it to say that unless the applicable fee agreement allows it, the health plan’s chosen pricing cannot be applied to contracted claims without violating that agreement. It is a frighteningly-popular misconception within the self-funded industry that network or other fee agreements generally allow health plans to apply the contractual discount on top of the plan’s chosen edits or reductions (including Medicare rates). Consider the example of a $50,000 claim subject to a mandatory contractual 10% discount, yielding a contractual payment rate of $45,000. The payor priced the claim at 150% of Medicare based on the Plan Document, which totaled $10,000. While the contractual rate would require that this claim be paid at $45,000, an alarming number of health plans and TPAs will apply that contractual 10% discount on top of the Medicare-based $10,000 (yielding payment of $9,000). Given the large discrepancy between payment of $9,000 and payment of $45,000, it is not difficult to assume that a contracted medical provider will push back, and hard.
The latter is a business issue; a “discount” is something that is allowed by the provider (typically in the contractual sense), whereas the excess or disallowed amount is, by definition, not agreed-upon in advance by the provider. Incorrectly using the term “discount” is problematic because not only is it incorrect, but it starts all parties out on the wrong foot – and working with a hospital to write off a bill is much more difficult when the provider goes into the conversation already thinking that the payor has tried to take advantage.
BAD NEGOTIATION TACTICS: NOT HAVING AN END-GAME
As has been proven time and time again, the state of the industry is such that medical providers are generally permitted to charge any amounts they choose. Charge masters are arbitrary yet still enforced by many courts, and providers are free to send patients to collections or file lawsuits when they have not received their full
APPLYING RBP PAYMENTS TO CONTRACTED CLAIMS
One of the hallmarks of a successful RBP program is patient protection, which can come in many forms – including direct contracts, case-by-case settlements, balancebill indemnification, attorney representation, and other options, depending on the particular program used. Settling claims is perhaps the simplest way of protecting patients; by eliminating balances via settlements, balance-billing is extinguished. Likewise, if a third party offers to indemnify the patient, then the patient is protected in that manner as well – and hiring litigation counsel on behalf of the patient can be an effective tool in combatting balance-billing or spurring settlement negotiations where a provider was otherwise hesitant to negotiate.
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1 Ranking of top stop loss providers in the United States based on yearly premium as of 06/09/2018 by MyHealthGuide Newsletter: News for the Self-Funded Community, and does not include managed health care providers.
Stop Loss Insurance is underwritten by ReliaStar Life Insurance Company (Minneapolis, MN) and ReliaStar Life Insurance Company of New York (Woodbury, NY). Within the State of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the Voya® family of companies. Voya Employee Benefits is a division of both companies. Product availability and specific provisions may vary by state. ©2019 Voya Services Company. All rights reserved. 881423 205914 - 07012019
billed charges – and some providers feel even more inclined to do that if the provider has been paid at a percentage of the Medicare rate. Many medical providers treat a Medicare-based payment as a personal assault on the value of their treatment and seek to abuse health plans even more because of that! Some consider there to be two “separate” responsibilities to settle RBP claims or otherwise provide patients an avenue of protection from balance-billing – a social responsibility, and a legal responsibility. The social responsibility can be thought of in terms of the employer’s desire to provide its employees with sufficient coverage and a desirable program of health insurance; even though reference-based pricing and balance-billing are permitted by law, most employers utilizing this type of model are typically loathe to allow patients to be balance-billed, and desire to settle claims as part of the normal RBP process. For many employers, seeing a valued employee be sent to collections or become the defendant in a hospital’s lawsuit is the worst-case scenario. There is, despite popular misconception, a legal responsibility to settle claims as well. A few years ago, the Department of Labor came out with set 31 of its series on Frequently Asked Questions on the Affordable Care Act. While previous guidance provides that balance-billed amounts do not count toward the
patient’s out-of-pocket limit, this FAQ indicates that that rule applies only when there is an “adequate network of providers” who will refrain from balance-billing. When there is no adequate network of providers, however, the guidance suggests that health plans must in fact pay for balancebilled amounts that exceed the patient’s out-of-pocket max. Although the Department of Labor has neglected to provide additional guidance and make sure people understand what the FAQ guidance really means, the general opinion is that health plans must have a systematic program of settling balance-bills one way or another – and in fact most health plans utilizing RBP do have some system, whether direct contracts, a narrow network, or simply making sure they settle claims on the back-end.
Best Practices, Best Results. From stable underwriting, to claim and compliance expertise, to our Orion Navigator medical resource, StarLine’s trusted team prides itself on offering the very best underwriting management experience. www.linkedin.com/company/star-line-group (508) 809-3179
STOP LOSS | CAPTIVE | PAYOR | PROVIDER | ACO | GROUP ACCIDENT
We watch the trends.
We share our knowledge.
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There’s no simple way to overcome the rising claims trend in today’s market. But we know that incorporating smart practices into our business model is helping us to gain more control of the situation. We’re making informed decisions based on data analytics and industry knowledge; using the insight of in-house experts to create thoughtful solutions; and choosing our cost containment partners wisely as we work to protect our clients’ financial well-being. Learn more about our efforts to help manage the unpredictable at hmig.com.
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Products are underwritten by HM Life Insurance Company, Pittsburgh, PA, HM Life Insurance Company of New York, New York, NY, or Highmark Casualty Insurance Company, Pittsburgh, PA.
This is certainly a relevant factor for reference-based pricing, but not necessarily one that is prohibitive. This is an indication that RBP must evolve in order to remain compliant – and evidence that the threat of walking away the negotiation table may not be an option for many health plans.
THINKING THAT RBP IS “ALL OR NOTHING”
When employers are sold on RBP by TPAs, brokers, or vendors, often those entities fall into the common sales trap of promoting only the positive aspects of RBP, without painting a full picture of some of the potential snares as well. As a result, since RBP results do tend to add value, many employers immediately jump to leaving their respective PPO networks and applying the RBP methodology to all claims. After all, more claims subject to RBP theoretically means more added value, right? In practice, however, it often proves extremely beneficial to utilize some system of agreements as part of the overall RBP process. This ensures that employees have “safe harbors” to visit, promoting employee security, ease of use, and even compliance (see above!). There are no pre-set requirements for what RBP is or is not; though many enter into it with a set of preconceived notions of how it should work, an RBP program can be tailored to suit a given health plan’s needs (subject to the vendor’s and TPA’s standard practices and capabilities, of course). Many health plans using RBP combine it with narrow networks, direct provider contracts, physician-only networks, or even primary networks (using RBP only for out-of-network claims). Since RBP is meant only for non-contracted claims (see above, again!), RBP can in theory be used for any claims that the health plan has not previously agreed to pay at a certain rate. On that note, the last point:
NOT REALIZING THAT RBP IS JUST U&C FOR THE MODERN ERA!
When providers say “we expect payment at U&C” or similar things, it can be useful to take a step back and think about what RBP really is. At its core, RBP is just a way of pricing claims. It’s not a unique type of health plan, nor is it a way of changing the claims processes. It’s simply a way to determine how much money to pay on a given claim.
“Hang on,” you may be saying, “but isn’t that what Usual and Customary is?” Yes, it is! RBP can be conceptualized in many ways, but one of the most familiar is as a way of determining U&C. Just like RBP, “Usual and Customary” is not necessarily a pre-set term with a welldefined meaning; it is the way that a health plan determines what is payable. Interestingly, hospitals tend to suggest that “U&C” has to be defined as what other area providers charge for the same service, yet there is no support for that requirement. In fact, many health plans define “usual and customary” as an amount that hospitals commonly accept as payment for a given code. That can take into account private payors and even – gasp! – Medicare. The employer determines the definitions within the Plan Document. If your plan defines its payable amount as U&C, and bases that amount on Medicare rates, then you can honestly say that your plan does pay U&C. In conclusion: take care to ask your vendor – or potential vendor – lots of questions about their processes and how they manage these and other elements of their respective programs. With so many vendors in the industry, there can be lots of conflicting information, so make sure you’ve got your facts straight prior to signing on the dotted line.
As Director of The Phia Group’s Provider Relations department, Jon Jablon routinely advises health plans, TPAs, brokers, various industry vendors, and stop-loss carriers regarding balance-billing, claims negotiation, provider and network contracting, and much more.
peace of mind
Weâ€™ve got your back. Four words that you want to hear when seeking to self-fund employee medical benefits, particularly when facing the potential costs and risks associated with a self-funded benefit plan. At Swiss Re Corporate Solutions, our integrative National Employer Captive program brings our brokers, payers and their clients extra peace of mind through protection against catastrophic claims. Designed for groups with 50-400 enrolled employees, this captive program allows a small or medium size employer to participate as a member of a risk bearing entity with like-minded employers, providing both peer support and long-term financial stability. Most importantly, captive members get to jointly control their own risk and spend only the money they use. Weâ€™re smarter together. corporatesolutions.swissre.com/eslcaptives Insurance products underwritten by Westport Insurance Corporations and North American Specialty Insurance Company. ÂŠ Swiss Re 2019. All rights reserved.
RAND REPORT HIGHLIGHTS DISPARITIES IN HOSPITAL PRICING, QUALITY
new report released by the Colorado Business Group on Health and the
Colorado Consumer Health Initiative has found that hospital pricing and outcomes varied widely and inexplicably across the state, demonstrating no reliable correlation between price and quality. Designed to empower employers and their employees to become more informed healthcare consumers, the report offers hospital-by-hospital pricing and clinical outcomes comparisons for each hospitalâ€™s highest- and lowest-performing services.
Written by Joanne Wojcik
Inpatient payments to Colorado hospitals ranged from just under Medicare reimbursement rates to as much as 329% of what Medicare pays, according to the report. Outpatient payments ranged from 123% of Medicare in Aspen to 782% of Medicare in Fort Morgan. Meanwhile, quality varied nearly as much within hospitals as it does across hospitals. Of the 50 Colorado hospitals offering a service in the top 25% of hospitals in the country, 32 of these same hospitals also offer a service in the bottom 25% of all hospitals in the country, the report found.
At AmWINS Group Benefits our team of specialists wakes up every morning committed to bringing your team innovative solutions to the opportunities and challenges you and your self-funded clients face. Thatâ€™s the competitive advantage you get with AmWINS Group Benefits.
The data in the report was derived from the RAND Corporation’s Price Transparency Project, which evaluated payment information from self-insured employers, health insurers and patients in 25 states, as well as outcomes data from hospitals, over a three-year period from 2015 to 2017. The study found that the prices paid to hospitals for privately insured patients averaged 241% of what Medicare would have paid, with wide variation in prices among states. Hospital quality performance was calculated using the Quantros CareChex Hospital and Health System Quality Rankings and Ratings with three years of clinical outcomes from the Centers for Medicare and Medicaid Services, the nation’s largest database of claims, combined with the Colorado All Payer Claims Database, which includes actual payments made by health insurers, employers and patients to providers. RAND’s Price Transparency Project will be featured during a session on “Using Reference-Based Pricing to Tame the Hospital Cost Shift” during the 2019 SelfInsurance Institute of America’s annual conference, which is being held Sept. 30-Oct. 2 in San Francisco. During the session, RAND Researcher Christopher Whaley will unveil the data that RAND has collected. Robert Smith, executive director of the Colorado Business Group on Health will share the information that RAND collected on Colorado, which turned out to be among the most expensive of the 25 states studied. Also during the session, Marilyn Bartlett, special projects coordinator for the Montana Commissioner of Securities and Insurance will share her state’s experience with implementing reference-based pricing using the RAND hospital pricing data.
Further details about the RAND Price Transparency Project are available here: https://employerptp.org/#visualize To learn more about the SIIA conference, visit www.siia.org
Celebrating 10 years of Employee Benefit Group Captives We’ve been innovating for a very long time. Ten years ago, Berkley Accident and Health was an industry pioneer with EmCap®, our employee benefit group captive program. Today, we are a market leader with an impressive track record of building and managing successful captives. For group captives, it’s a clear choice. Choose the team with a decade of experience and success. These statements are illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.
© 2018 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved. BAH 2018-14
Specialty Accident www.BerkleyAH.com
SIIA Future Leaders Mentor Connection Forum
he Self-Insurance Institute of America, Inc. (SIIA) launched the SIIA Future Leaders (SFL) initiative in fall of 2018, designed to encourage talented younger professionals to become involved with the association and the self-insurance industry. The SFL has had several events since its launch including a stand-alone forum in December of 2018, a mini-program held in conjunction with SIIAâ€™s Self-Insured Health Plan Executive Forum, and a mentor connection forum. There will be many educational and networking opportunities for Future Leaders at the 2019 SIIA National Conference & Expo will be September 30th - October 2nd at the San Francisco Marriott Marquis.
ENDEAVORS The Future Leaders Educational Session Track includes:
will explain how SIIA works in Washington, DC and various state capitals to support the interests of its members and the different ways that you can get involved to help the industry, with the side benefit of rounding out your professional experience.
MOVING FROM RANK-AND-FILE TO MANAGEMENT
A panel of seasoned SIIA Future Leaders, each between the ages of 30 and 40, will present advice and share experiences with other younger SIIA Future Leaders in an informal “Town Hall-style” Q&A session. Brady Bizarro, Director, Healthcare Attorney at The Phia Group, LLC will serve as moderator to panelists Craig Clemente, Chief Operating Officer of Specialty Care Management and Chairman, SIIA Future Leader Committee, Lindsay Harris, Chief Client Officer of Healthcare Management Administrators, Inc., and Ron Peck, Esq., SVP & General Counsel of The Phia Group, LLC.
This session will feature key learnings from members of SIIA’s Future Leaders who were promoted from rank-and-file roles into management positions, including what pitfalls to avoid and their secrets for success. How did they get noticed? What role did mentors play? What advice do they have for others seeking to climb their career ladders to the top? Panelists include Alyssa Mattas, Underwriting Manager of Swiss Re Corporate Solutions, Michelle Marzella, Assistant Vice President of D.W. Van Dyke & Company, and Lisa Hodson, Director of Product Management and Development of Allied National, Inc.
PREPARING FOR A NEW GENERATION OF SELFINSURANCE POLITICAL ADVOCACY For more than 30 years, many individual SIIA members have gotten directly involved to support the association’s political advocacy efforts at the federal and/or state level…and this involvement has often made a real difference. With a generational change now starting to take place within SIIA, it is critically important that the association’s younger members understand the importance of this involvement and how they can get plugged in, in order to help ensure the ongoing viability of our industry. Adam Brackemyre, Vice President, Government Relations of SIIA and Ryan Work, Vice President, Government Relations, of SIIA
THE MILLENNIAL MANAGER: HOW TO MANAGE OLDER GENERATIONS As more and more Millennials and Gen-Xers are promoted into management positions, there are times when they may be called on to oversee older workers. Taking into consideration generational differences in workstyles and communications, how can they approach this charge without creating friction? What, if anything, have they learned from these seasoned professionals? Conversely, what have they taught their peer-elders? Panelists include Craig Clemente, Chief Operating Officer of Specialty Care Management, Brad Roehrenbeck, General Counsel & VP, Legal Services and Compliance of Medcost, and Robert Kerr III, Senior Vice President of Tokio Marine HCC - Stop Loss Group.
WORKING SIIA - WHAT YOU NEED TO KNOW Many of the most successful executives within the self-insurance industry have been active SIIA members – that is no coincidence. SIIA offers multiple involvement and networking opportunities that can help you build a positive professional reputation, contribute to your organization’s financial success and advance your education. The featured speaker for this session, Duke Niedringhaus, Senior Vice President of JW Terrill - Marsh & McLennan Agency, has done it all within SIIA for more than a decade–committee member, committee chairman, speaker, moderator and director. Based on this experience, he will share his insights on how to “work SIIA” to further your career advancement goals while adding current value to your employer. In addition to the SIIA Future Leaders (SFL) educational track, the SIIA Future Leaders are invited to an exclusive pre-party networking event from 7:00 pm - 8:30
ENDEAVORS pm at August Hall. This event will be held prior to SIIA's National Conference Party. Transportation from the San Francisco Marriott Marquis will be provided.
Craig Clemente, Chief Operating Officer of Specialty Care Management and Chairman, SIIA Future Leader Committee states “being the Chairman of the SIIA Future Leaders for the past couple years has been a tremendous experience and I am truly excited and proud of what has been accomplished. We have a wonderful group that has worked hard taking the SFL from concept, applying focused growth hacking strategies, to create a successful and sustainable
initiative we have today. As a committee we want to thank and acknowledge all of the SIIA member organizations that have supported us and continue to do so, as well as all the other individuals and organizations that have supported this critical initiative. We believe that the events and educational opportunities in San Francisco will we be informative and continue to provide great value to our SFL registrants. See you in San Francisco!”
If you have Future Leaders in your company that you would like to direct to this initiative, or if you are a future leader yourself, we invite you to join the SIIA Future Leaders LinkedIn Group at www.linkedin.com/groups/12098226.
More information on SIIA’s Future Leaders initiative and the 2019 SIIA National Conference & Expo, including registration, can be found at www.siia.org.
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NEWS FROM SIIA MEMBERS
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 firstname.lastname@example.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. For immediate assistance, please contact Jennifer Ivy at email@example.com. If you would like to learn more about the benefits of SIIAâ€™s premium memberships, please contact Jennifer Ivy at firstname.lastname@example.org. 54
When a fever disrupts a daily routine or the results of a routine test disrupt your everything, we're here to help. From episodic illnesses to the most complex and costly medical conditions, Teladoc Health is transforming how people access healthcare. In 2002, we set out to find a better way to connect doctors and patients. Today, we are the world's largest and most trusted provider of virtual care services. With an award-winning user experience and scalable technology platform, Teladoc Health provides access to high-quality care for millions of people around the globe.
TeladocHealth.com I 1-844-798-3810 313621825 I 01302019
ÂŠ 2019 Teladoc Health, Inc. All rights reserved.
DIAMOND MEMBERS JAY RITCHIE NAMED PRESIDENT OF TOKIO MARINE HCC – STOP LOSS GROUP HOUSTON -- Tokio Marine HCC announced that Jay Ritchie, Executive Vice President and Chief Operating Officer of Tokio Marine HCC – Stop Loss Group (TMHCC – Stop Loss Group), has been promoted to President, effective August 1, 2019, succeeding Daniel Strusz who will continue to serve the division as Chairman. Susan Rivera, Chief Executive Officer of Tokio Marine HCC, congratulated Mr. Ritchie and commented, “Jay has been an employee of TMHCC for the past 23 years, has served in various management positions and has been instrumental in the success of the organization, including the stop loss captive business and Taft Hartley self-funded plans. He has also been very involved in the industry, serving the Self-Insurance Institute of America (SIIA) as Chairman of the Government Relations Committee, as well as Chairman of the Self Insurance Political Action Committee, before becoming Chairman of the Board in 2017.” Mr. Strusz added, “I look forward to continuing to work with Jay as we strategically grow our stop loss and organ transplant blocks of business. I am also excited to work with Jay and our partner firms as we find solutions for employer groups in the self-funded industry.” Today, TMHCC covers over 3,000 self-funded employers and union plans for medical stop loss and
another 1,000 groups with organ transplant insurance. By listening to the demands of the market, TMHCC has developed exceptional products, unparalleled resources and value-added services that set it apart in the industry.
“I am excited to assume this position within our organization as we strive to deliver even greater value to self-funded employers and our producers. Our market continues to evolve with new challenges, and we see great opportunity to continue to build on our capabilities and cost management solutions for our clients and their members.” Mr. Ritchie stated,
About Tokio Marine HCC Tokio Marine HCC is the marketing name used to describe the affiliated companies under the common ownership of HCC Insurance Holdings, Inc., a Delaware incorporated insurance holding company. Headquartered in Houston, Texas, Tokio Marine HCC is a leading specialty insurance group with offices in the United States, the United Kingdom and Continental Europe. Tokio Marine HCC’s major domestic insurance companies have financial strength ratings of “AA- (Very Strong)” from S&P Global Ratings, “A++ (Superior)” from A.M. Best, and “AA(Very Strong)” from Fitch Ratings; its major international insurance companies
C O M PA N I O N L I F E I N S U R A N C E C O M PA N Y
Set the Course. At Companion Life, you can count on teamwork with individual attention. That’s a real advantage. We anticipate trends, identify opportunities, but, most importantly – we listen to you. We brainstorm with our partners. STOP LOSS
Together, we create products and solutions or carve out new
LIMITED BENEFIT HEALTH PLANS
distribution channels to get an early foothold in the market.
SHORT TERM MEDICAL MEDICARE SUPPLEMENT LIFE
We focus on relationships and listening. Together, we’ll go places. Call us. Let’s let our ideas take flight.
DENTAL SHORT TERM DISABILITY LONG TERM DISABILITY VISION CRITICAL ILLNESS
Rated A+ by A.M. Best Company. Rating as of December 18, 2018. For the latest rating, visit ambest.com
NEWS have financial strength ratings of “AA- (Very Strong)” from S&P Global Ratings. Tokio Marine HCC is a member of the Tokio Marine Group, a premier global company founded in 1879 with a market capitalization of $34 billion as of December 31, 2018. Visit www. tokiomarinehcc.com. About Tokio Marine HCC – Stop Loss Group Tokio Marine HCC – Stop Loss Group is the marketing name used to describe the medical stop loss and organ transplant-related insurance operations of Tokio Marine HCC through its wholly owned subsidiary HCC Life Insurance Company (HCC Life). HCC Life is a leading provider of medical stop- loss
insurance through brokers, consultants and third party administrators. The Company has financial strength ratings of “AA- (Very Strong)” from S&P Global Ratings, “A++ (Superior)” from A.M. Best, and “AA- (Very Strong)” from Fitch Ratings. HCC Life is backed by the financial strength of its parent company, HCC Insurance Holdings, Inc. Visit www.tokiomarinehcc.com/life.
GOLD MEMBERS AMERICAN FIDELITY NAMED ONE OF PEOPLE’S 50 COMPANIES THAT CARE Oklahoma City, OK – PEOPLE magazine and Great Place to Work selected American Fidelity as one of their 2019 50 Companies That Care. “Our Customers are the backbone of our communities – educators, police, firefighters, municipal workers, healthcare providers – and they inspire us to give back,” said American Fidelity President and COO Jeanette Rice. “Whether it’s donating blood, tutoring at a local school, serving as a Pacesetter for the United Way campaign or volunteering at a local food bank, our Colleagues are always willing to help their communities. We’re a company that cares because our Colleagues care.”
• Quoting Process & Dashboard • Real-Time Notifications • Repository for Contract Details
• Spec and Aggregate Reporting • Trigger Diagnosis Notifications • Track Domestic Spend vs Savings
NEWS To celebrate making the list, American Fidelity is rolling out a new volunteer grant program for its Colleagues and has special volunteer activities planned for Colleagues. Along with an existing match for Colleagues’ donations to eligible charitable organizations, the new program will offer monetary donations to match the time Colleagues spend volunteering for eligible charitable organizations and Colleagues serving on non-profit boards can also receive donations for their organization. Here are just a few of the other ways American Fidelity cares for the community:
American Fidelity sponsors campaigns for the United Way, Allied Arts and Regional Food Bank of Oklahoma annually, in addition to monthly charity days for organizations nominated by Colleagues. The Company also supports schools and charities in the communities where they do business.
AF sponsors the NBA Oklahoma City Thunder’s literacy programs including the Rolling Thunder Book Bus, Teacher of the Game, Read to Achieve Reading Timeouts and the Reading Challenge. Since its debut in 2007, the Rolling Thunder Book Bus has distributed nearly 170,000 books and visited about 2,000 schools and day care groups.
Colleagues receive 20 hours paid volunteer time annually.
AF has hosted more than 100 blood drives and supports the American Red Cross.
Through a partnership with KFOR Channel 4, American Fidelity helps provide weather curriculum that teachers can use in the classroom. In addition, meteorologists from the station take Weatherschool live to visit about 20 schools per year.
• Through the AF Teacher Fellowship STEM teachers work in American Fidelity’s software development, enterprise information management or technical infrastructure areas for the summer. They will take this experi-
NEWS ence back to the classroom to help students learn about and prepare for careers in technology. Plus, they received a $2,000 stipend to use for their classrooms upon completion of the program.
Colleagues can help each other through a Colleague Relief Fund, which provides assistance to Colleagues going through unexpected events
Published by PEOPLE, the Companies that Care list highlights the top US companies that have succeeded in business while also demonstrating outstanding respect, care and concern for their employees, their communities and the environment. PEOPLE magazine teamed up with Great Place to Work® to produce the ranking using the workplace analytic firm’s extensive database and inside knowledge of outstanding workplaces around the globe. Rankings are based on surveys representing over 4.5 million employees’ experiences of how their workplaces have made a difference in their lives and in their communities. Rankings also reflect Great Place to Work’s assessment of the generosity of each organization’s benefits, philanthropic and community support, with particular focus on activities occurring in the last year. About American Fidelity American Fidelity Assurance Company has served the employer stop loss market for more than 25 years under the stable ownership of the Cameron family. More information can be found at americanfidelity.com/stoploss. American Fidelity has earned an “A+” (Superior) from the A.M. Best Company since 1982. One of the nation’s leading insurance company rating services, A.M. Best conducts a strict review process for financial stability every year. American Fidelity has been recognized as one of the “100 Best Companies to Work for in America” by global research and consulting firm Great Place to Work® and Fortune Magazine 11 times. The Company was also selected for several other lists by Fortune, including: Best Workplaces for Millennials, Best Workplaces in Finance and Insurance, Best Companies for Giving Back, Best Workplaces for Women, Best Workplaces for Diversity and the Human Capital 30: Companies that Put Employees Front and Center.
HEALTH PLANS, INC. (HPI) NAMES DREW ROZMIAREK AS SVP OF NATIONAL SALES Fueled by explosive national growth, HPI has tapped Drew Rozmiarek to be their senior vice president of national sales and emerging markets. Drew will oversee HPI’s sales team outside of New England to magnify their national sales presence and market development across the country. He brings 20 years of experience in the self-funded health plan industry and extensive knowledge of employee benefit captives, value-based pricing, new product development and strategic initiative development.
“HPI is a team of forward-thinking entrepreneurs rooted in 35 years of TPA experience,” said Deb Hodges, president and CEO of HPI. "The addition of Drew to our team will further accelerate our ability to bring HPI’s creative approach and self-funding best practices to companies across the country.” Most recently, Drew served as the director of sales and specialty services at Cypress Benefit Administrators and led the TPA’s self-funded emerging markets and new product development in the Western U.S. Previously, he served as regional vice president at A&G Healthcare Services.
D O NE RIG HT WE HAVE THE EXPERTISE, EXPERIENCE AND BULLDOG TENACITY TO DO THE JOB AND DO IT RIGHT
o two groups are exactly alike and no one Reference Based Pricing program design is right for them all. That’s why HHC Group starts by learning each group’s objectives and constraints. Then we help design and implement the right Reference Based Pricing program for them. Some want pre-cert and concierge services. Others want just claims repricing or repricing, provider appeal support and patient advocacy. Some want customized models and some provider contracting. We have the experience and expertise to help the group design and deliver the RBP program that’s just right for you.
CONTACT US sales@HHCGroup.com www.HHCGroup.com Claims Negotiation & Repricing | Claims Editing | Medical Bill Review (Audit) | Reference-Based Pricing DRG Validation | Utilization Reviews and Independent Reviews | Independent Medical Examinations
NEWS “By joining HPI, I have an amazing opportunity to create health plan management solutions that this industry is craving,” Rozmiarek said. “I’ve spent my entire career in the self-funded benefit space. Throughout, I’ve been a big proponent of plan evolution, and the key role that a TPA plays in that evolution, as a vital component to a plan’s success. I am honored and excited about the opportunity to drive HPI’s national
expansion and facilitate evolution and success across the country.”
AMHERST, NY -- Nova Healthcare Administrators has grown its medical membership base from 11,000 in 2011 to 122,000 to date in 2019. Due to the company’s rapid growth, company leaders filled 38 new jobs in 2018, expect to add up to 20 additional new employees in the remaining months of 2019 and 50 more new jobs over the next three years, to supplement the current workforce of more than 200.
Health Plans, Inc. (HPI) is one of the largest administrators of employee health benefit plans and population health management services in the country. Founded in 1981, we share our expertise, innovation and proven, cost-saving solutions with partially self-funded employers to solve their unique health and benefit challenges. It is our flexible approach, entrepreneurial spirit and commitment to quality, technology, and service that enable us to deliver premium value to our customers. HPI is a Harvard Pilgrim company. Contact Su Doyle, Director of Strategic Marketing, at 508-475-6103, email@example.com and visit www. HealthPlansInc.com.
ADMINISTRATORS CONTINUES NATIONWIDE GROWTH ATTRACTING INNOVATIVE CLIENTS AND BOOSTING
NEWS Beyond traditional medical administrative services, Nova supports plans leveraging in-house medical management, HSA, FSA and HRA products. Nova also provides a variety of private-labeled administrative solutions, COBRA, vision, and reimbursement account services to clients, with membership spanning 37 states. Nova’s innovative approach to managing self-funded medical plans continues to attract clients, growing from 15 clients in 2011 to 130 in 2019, creating 166 jobs over the last eight years. “In today’s health care environment, it’s vital for employers to maximize the value of their health care spend,” noted Jamie Farrell, Director, Health Plan Performance Management. “Taking a
customized approach to trend management, and a thoughtful, proactive approach to plan management, results in improved health outcomes and reduced costs, which benefits plan sponsors, their members, and their families.” Nova’s ability to attract the attention of prospects comes as the result of years of work to hone an approach that maximizes plan data, engages in client partnerships, and delivers results. Recognized as one of Modern Healthcare’s Best Places to Work in Healthcare 2019 and Best Companies to Work for in New York, Nova focuses on creating a work environment that supports associates and provides opportunities for growth within the company. “In creating an environment where associates can grow in their role and within the company across departments, we increase opportunities to attract and retain talent. This translates to associates who become invested in our business and our clients and our shared success, added Farrell.” Nova is URAC accredited for Health Utilization Management and Case Management. URAC is the independent leader in promoting healthcare quality through accreditation, certification and measurement.
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Proud 2018 Diamond Members
NEWS By achieving this status, Nova has demonstrated a comprehensive commitment to quality care, improved processes and better patient outcomes. In recognition of their commitment to quality Nova was awarded the Certificate of Validation by Care Innovations™ Validation Institute, whose goal is to evaluate organizations performing population health management. This nationally recognized certificate is only awarded to organizations that compete on the basis of integrity and proven performance. Additionally, Nova was recently selected as the winner in the Population Health Management/Patient Engagement Solutions category for Health Plan Performance Management by the Fierce Innovation Awards: Healthcare Edition for their work throughout 2018. Nova was also recognized as Best in Show for the fiercest engagement solution for Health Plan Performance Management. A panel of judges from the nation’s top health care systems, medical practices and accountable care organizations (ACOs) awarded companies based on their potential for cost savings, increased plan participant engagement or overall industry innovation. Nova’s commitment to clients and associates creates an environment where engaged employees provide creative, innovative solutions to meet the unique needs of a diverse and ever-growing client base. About Nova Headquartered in Buffalo, NY, Nova is a wholly-owned affiliate of Independent Health. Evolving over the last 30 years, Nova aims to manage trend to reduce health care spend and improve health plan performance. Nova works with flexibility to provide clients the solutions they need in the way they need them including medical, dental, vision, COBRA, reimbursement account administration, and private-labeled partnerships. Nova provides clients with flexible plan design, national network solutions, customized trend management strategies and personalized service. Visit www.novahealthcare.com.
D.W. VAN DYKE MEDICAL STOP LOSS INDUSTRY TARGET LOSS RATIO SURVEY PROGRESS UPDATE
January periods (15,16,17,18). DWVD’s most recent January 2019 Persistency and New Business surveys had 34 participants (MGU’s and Direct carriers) exceeding $8.5 Billion of Annualized Stop Loss premiums. All Stop Loss organizations (Carrier and MGU) are welcome and invited to participate. As always, strict confidentiality applies to all participant survey information/data with all results presented in a blended/aggregate format. Those interested in participating should contact Joe Sabol at jsabol@ dwvd.com, Chris Koehler at ckoehler@ dwvd.com or Michelle Marzella at firstname.lastname@example.org.
About D.W. Van Dyke & Company Founded in 1978, DWVD provides intermediary and advisory support for reinsurance placements, distribution, product development consulting and direct brokering services on behalf of institutional clients. DWVD works throughout the Life, Accident & Health space, most prominently in the stop loss business. DWVD's customers and markets include Insurance Companies, Reinsurers, TPAs, MEWAs, Cooperatives, MGAs, distribution companies and others. Contact Walt Roland at email@example.com and visit www. dwvd.com.
Michelle Marzella, Vice President at D.W. Van Dyke & Co., Inc., announced that questionnaires had been sent inviting Stop Loss Carriers and MGU’s to participate in D.W. Van Dyke & Co., Inc’s Medical Stop Loss Industry Target Loss Ratio Survey. DWVD anticipates strong participation as survey results should be a strong indicator of Industry loss ratio’s relative to pricing expectations over the most recent “complete”
Delaware Advantage • Delaware takes captive insurance company licensing to a new level that Speeds to Market the licensing process. • Delaware is the first in the nation to electronically offer a conditional certificate of authority as part of the general application. • Delaware’s conditional certificate of authority means receiving a license to conduct insurance business the same day of submitting the application to do business.
STEVE KINION, DIRECTOR Bureau of Captive & Financial Products Department of Insurance
BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS Delaware Department of Insurance 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280 | captive.delaware.gov Trinidad Navarro, Insurance Commissioner
SIIA 2019 BOARD of directors & committee chair ROSTER
CHAIRMAN OF THE BOARD*
Adam Russo Chief Executive Officer The Phia Group, LLC Braintree, MA
Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston-Salem
Mary Catherine Person President HealthSCOPE Benefits, Inc. Little Rock, AR
CAPTIVE INSURANCE COMMITTEE John R. Capasso, CPA, CGMA, PFS President & CEO Captive Planning Associates, LLC Medford, NJ
Kevin Seelman Senior Vice President Lockton Dunning Benefit CompanyDallas, TX
Mike Ferguson SIIA Simpsonville, SC
David Wilson President Windsor Strategy Partners, LLC Princeton, NJ
TREASURER AND CORPORATE SECRETARY* Gerald Gates President Stop Loss Insurance Services AmWins Worcester, MA *Also serves as Director
SIEF BOARD OF DIRECTORS Nigel Wallbank Chairman Heidi Leenay President Freda Bacon Director
Jeffrey K. Simpson Partner Womble Bond Dickinson (US) LLP Wilmington, DE Robert Tierney President StarLine East Falmouth, MA Peter Robinson Managing Principal Integro Re San Francisco, CA
GOVERNMENT RELATIONS COMMITTEE Steven B. Suter President & CEO Healthcare Management Admtrs., Inc. Bellevue, WA CHAIR, INTERNATIONAL COMMITTEE Liz D. Mariner Ford Senior Vice President Re-Solutions, a Risk Strategies Company Minneapolis, MN CHAIR, SIIA FUTURE LEADERS COMMITTEE Craig Clemente Chief Operating Officer Specialty Care Management Lahaska, PA CHAIR, TPA BEST PRACTICES TASK FORCE Ron Dewsnup President Allegiance Benefit Plan ManagementMissoula, MT CHAIR, WORKERSâ€™ COMP COMMITTEE Mike Zucco Business Development ATA Comp Fund Montgomery, AL
Les Boughner Director Alex Giordano Director
SIIA new members SEPTEMBER 2019
REGULAR CORPORATE MEMBERS Lisa True Cofounder and Co-CEO Aither Health Carrollton, TX
David Guttman President First Stop Health Chicago, IL
Vikki Columbus Chief Pharmacy Officer SGRX Grosse Pointe Park, MI
Sheryl Wainwright President/CEO Aratai International, LLC St. George, UT
Joanne Eason Vice President Partner Relations Five Wishes Tallahassee, FL
Evan Bruder Sona Benefits Asheville, NC
Ben Gardner SVP Sales and Marketing Archway Health Boston, MA Sarah Hazel Marketing Coordinator Brady, Connolly & Masuda, P.C. Chicago, IL Aaron Kessinger President CareValet Tampa, FL John Kirke Executive Vice President CCIG Greenwood Village, CO Glenda Marple President/CEO CPM, Inc. Topeka, KS Justin Hajek DialCare Frisco, TX David Goldfarb President DSG Benefits Group, LLC Dallas, TX
Bret Brummitt Advisor Generous Benefits Coppell, TX
Arvind Ranganthan President Synthesis Healthcare Services LLP Chennai, Tamil Nadu
James Patton Partner HealthVue360 Austin, TX
Dominic Hagger President Tatum Reinsurance Intermediary, LLC Red Bank, NJ
Dave Kazynski President HOMELINK Waterloo, IA
Norman Chandler President TaylorChandler Montgomery, AL
Holly Taylor Vice President & General Manager Keet Health Austin, TX
Daniel Smith President Western Skies MGU, LLC Las Vegas, NV
Russell Carpel CEO LevelFunded Health Weston, FL William Jones CEO Paydhealth LLC Plano, TX Brittany Shaw Firm Operations Manager Rives & Associates, LLP Lexington, NC
SILVER CORPORATE MEMBER Matthew Lund CEO/President Fortune Management, Inc. Seattle, WA
EMPLOYER CORPORATE MEMBER Phillip Holowka medTRANS Insuranace, Ltd Pittsburgh, PA
AFFILIATE MEMBER Andrej Pantar Director of Sales Mikropis USA LLC Rochester, MN
OUT-OF-NETWORK CLAIMS ALERT
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