Health Care Delivery

[Guidance Overview] HHS's Proposed HITECH/HIPAA Privacy, Security and Enforcement Guidance
Excerpt:"HHS has requested comments on the proposed HITECH regulations on or before September 13, 2010. Once the final regulations are issued, HHS has indicated that covered entities will generally have 180 days to comply with the new rules. HHS also indicated that there would be no additional delay of the application of the regulations, once finalized, to small health plans."(McDermott Will&Emery)

[Guidance Overview] Reimbursing OTC Drugs and Applying for Mini-Med Waivers
Excerpt:"On September 3, 2010, the Internal Revenue Service (IRS) and the Office of Consumer Information and Insurance Oversight (OCIIO) independently announced the release of additional Affordable Care Act guidance."(Kilpatrick Stockton LLP)

[Guidance Overview] HHS Guidance on Annual Dollar Limit Waivers for Limited Benefit Health Plans or'Mini Med'Plans
Excerpt:"The waiver process is available for group health plans and health insurance issuers if the plan or coverage was offered prior to September 23, 2010 for the plan or policy year beginning between September 23, 2010 and September 23, 2011."(Hewitt Associates)

[Guidance Overview] The ERISA Litigation Newsletter, September 2010
Excerpt:"[The] focus this month is on the Third Circuit's decision in In re Visteon, which held that Section 1114 of the Bankruptcy Code applies to all retiree benefits -- vested and unvested -- and, as a result, a plan must continue to pay unvested retiree benefits during the pendency of bankruptcy unless the bankruptcy court approves otherwise."(Proskauer Rose LLP)

[Opinion] Uwe Reinhardt on the Details of the Medical Loss Ratio
Excerpt:"The recently passed Affordable Care Act requires heath insurance issuers to use at least some minimum fraction of revenue from the premiums it receives on medical services. While the idea might sound straightforward, this fraction, known as the'medical-loss ratio,'is open to all sorts of creative arithmetic, and you can bet that interest groups from every corner are trying to get the math to add up in their favor."(Physicians for a National Health Program)

HHS Guidance on Waivers for Health Plan Limits
Excerpt:"Under current restrictions, annual limits for plans beginning between Sept. 23 and Sept. 22, 2011 cannot be lower than $750,000 . . . ."(Henry J. Kaiser Family Foundation)

U.S. Health Care Trend Survey, Summer 2010 (PDF)
7 pages. (Aon Consulting)

Where Americans Get Acute Care: Increasingly, It's Not at Their Doctor's Office
Excerpt:"Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care -- treatment for newly arising health problems -- are made to patients'personal physicians."(Health Affairs)

Mental Health Parity Act May Affect Your Medical Benefits
Excerpt:"The law takes effect at the beginning of a health plan's new year, so many people won't see any changes until January. At that point, people who will see the most benefit are those who previously had high copays and deductibles on mental health services."(Los Angeles Times)

Insurers Adjust Standards for Doctors and Hospitals
Excerpt:"While this push by insurers on quality implies that consumers will get better care because doctors and hospitals will be measured against the best performers, there may be an unintended consequence: It could leave patients with fewer choices of medical care providers, depending on which health plans they purchase."(Chicago Tribune)

[Guidance Overview] What External Review Requirements Must be Met Under PPACA
Excerpt:"These new requirements apply to both individual and group health plans (insured and self-funded), but do not apply to grandfathered plans."(PLANSPONSOR.com)

[Opinion] Who Should Provide Anesthesia Care?
Excerpt:"The issue is potentially important to patients and to health care reformers seeking to restrain costs and reduce reliance on high-priced medical specialists."(The New York Times; free registration required)

Health Care Wastefulness Is Detailed in Studies
Excerpt:"In a snapshot of systemic waste, researchers have calculated that more than half of the 354 million doctor visits made each year for acute medical care, like for fevers, stomachaches and coughs, are not with a patient's primary physician, and that more than a quarter take place in hospital emergency rooms."(The New York Times; free registration required)

[Guidance Overview] Guidance and Model Notices Issued on Reviews of Health Benefit Claims (PDF)
2 pages. Employer actions are suggested. (Milliman)

[Guidance Overview] More Guidance on Claims and Appeals Requirements for 2011
Excerpt:"In general, . . . self-funded plans should know: Self-insured group health plans have been granted an interim enforcement safe harbor until further notice. In order to avoid penalty during the enforcement safe harbor, a self-insured group health plan must either (a) comply with the standard and expedited external review procedures detailed in the guidance (which are based on the new state minimum procedures), or (b) voluntarily comply with a state process (assuming that the state is willing to allow access to its external review process). The agencies intend to issue additional guidance in the future with model language for the plan's SPD, describing the plan's new internal claims and appeals and external review procedures."(Holland&Hart LLP)

[Guidance Overview] ERISA Plan's Reimbursement Claim Enforced Against Disbursed UIM Benefits
Excerpt:"This is a very significant opinion addressing ERISA health plan subrogation. . . . U.S. Airways v. James McCutchen et al presents a set of facts typical of an ERISA health plan subrogation case."(Roy Harmon via Health Plan Law)

[Guidance Overview] Federal External Review of Benefit Claims and Appeals under Health Care Reform
Excerpt:"This'WorkCite'deals specifically with a new federal process for the external review of benefit claims and appeals under self-insured group health plans that are not'grandfathered'plans under the Act."(McGuireWoods LLP)

State Reform Dominates Boston, Massachusetts, Health Care Market Dynamics
Excerpt:"A key provision of Massachusetts'health reform law was the merger of the small group and individual, or nongroup, insurance markets, which was designed to make premiums more affordable for individual purchasers."(Center for Studying Health System Change)

NAIC Approves Form for Medical Loss Ratio Reporting
Excerpt:"The National Association of Insurance Commissioners (NAIC) Executive Plenary Committee has approved final implementation of a medical loss ratio (MLR)'blanks'to implement Public Health Service Act 2718 as added by the Patient Protection and Affordable Care Act."(Wolters Kluwer)

[Guidance Overview] Additional Guidance for Plan Sponsors on Health Benefits Appeals and External Review Processes (PDF)
4 pages. (Buck Consultants)

[Opinion] Hewitt Comments on Interim Final Rules Related to Lifetime and Annual Limits, Rescissions
Excerpt:"Hewitt's comment letter . . . addresses several issues as they relate to employer-sponsored health plans, including: Lifetime and Annual Limits; Definition of Essential Health Benefits; Rescissions; Mini-Med Waiver Program[.]"(Hewitt Associates)

[Guidance Overview] Internal Claims and Appeals and External Review Process under Health Care Reform (PDF)
4 pages. (Reinhart Boerner Van Deuren s.c.)

[Guidance Overview] Model Notices for PPACA's Claims and Appeals Regulation and Interim Guidance on the Federal External Review Process (PDF)
6 pages. Excerpt:"On August 23, 2010, [DOL, HHS, and Treasury] jointly released model notices that non-grandfathered plans and health insurance issuers may use to satisfy new requirements under [PPACA] regarding adverse benefit determinations and appeals of adverse benefit determinations."(Groom Law Group)

Medical Errors in 2008 Cost the U.S. Almost $20 Billion
Excerpt:"These are just the quantifiable costs, including higher medical costs attributable to the errors, and costs associated with higher mortality rate and costs resulting from lost productivity . . . ."(Wolters Kluwer)

Employers Plan to Increase Health Coverage Cost Sharing Next Year, According to Survey
Excerpt:"An Aon news release said the poll also found that 57% of companies will ask employees to contribute more for the overall cost of health care in 2011."(PLANSPONSOR.com)

[Guidance Overview] ERISA Plan Wins Recovery from Settlement; Auto Insurer Must Reimburse Member
Excerpt:"This is the first time we've seen a case where a federal district court ruled that a Michigan no-fault auto insurer now has to pay more than its maximum plan liability when a health plan subject to ERISA recovered a substantial portion of the tort settlement proceeds it paid."(Passion for Subro)

[Guidance Overview] Interim Procedures for Federal External Review and Model Notices under Health Reform (PDF)
4 pages. Excerpt:"Grandfathered health plans are not subject to any of the claims and appeals changes under PPACA, including the external review. However, if a group health plan or benefit package/option that is part of a group health plan loses its grandfathered health plan status, it must comply with these new claims and appeals requirements."(Hewitt Associates)

[Opinion] Putting a Lid on Health Care Inflation Is Possible
Excerpt:"This may well sound pie-in-the-sky-- and I'm not suggesting that we'll do it. Still, if you believe the many observers who suggest that at least one-third of our health care dollars are squandered in ways that provide no benefit to patients, in theory, we should be able to slice spending by 25%."(The Century Foundation)

'Meaningful Use'of Electronic Health Records
Excerpt:"Starting in May 2011, the federal government will begin paying bonuses to doctors, clinicians, and hospitals that have adopted the use of electronic health records (EHRs). From now until 2016 individual doctors and other providers may earn up to $44,000 from Medicare or $63,750 from Medicaid, and hospitals can earn millions of dollars, if they can demonstrate they are making'meaningful use'of EHR systems."(Health Affairs)

[Official Guidance] Text of Technical Release on Interim Procedures for Federal External Review Relating to Internal Claims and Appeals and External Review Under PPACA (PDF)
8 pages. (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Model Notice of Adverse Benefit Determination
2 pages. (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Model Notice of Final Internal Adverse Benefit Determination
2 pages. (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Model Notice of Final External Review Decision
2 pages. (U.S. Employee Benefits Security Administration)

South Carolina Will Spend $2.4 Million on Bariatric Surgeries for State Workers
Excerpt:"After monitoring the participants for a year and a half, the pilot program will check for complications and see if the surgeries lead to health-care savings."(Governing)

Health Law Requires Continued Insurance Coverage for Patients in Clinical Trials
Excerpt:"The law requires health plans to pay the routine care costs of patients who participate in clinical trials for the prevention, detection and treatment of cancer and other life-threatening conditions."(Henry J. Kaiser Family Foundation)

[Guidance Overview] New Internal and External Review Requirements for Claims and Appeals Procedures under Reform
Excerpt:"Effectively, these new requirements mean that group health plans must review appeals immediately upon receipt to allow for potential interim'mini appeals'prior to the deadline for responding to the appeal. In addition, plans that currently allow for two levels of appeal might consider reducing that to one to maximize the time allowed for the above process to take place."(Jones Day)

Health Care Reform Could Cost Health Insurers Far More Than Expected
Excerpt:"'As long as their investment incomes hold up, most large insurers should be able to handle the increased medical expenses expected under the new health care reform,'commented Martin D. Weiss, president of Weiss Ratings.'If investment income declines significantly, however, few insurers will be able to comply without debilitating impacts to their bottom line, and ultimately, their financial stability as well.'"(Wolters Kluwer)

[Guidance Overview] Guidance on Claims and Appeals Procedures for Group Health Plans Under Health Reform
Excerpt:"Under the regulations, group health plans must provide notices of an adverse benefit determination and of available internal claims and appeals procedures and external review processes in a culturally and linguistically appropriate manner, including in a non-English language if 25 percent of all participants are literate in the same non-English language (for plans with 100 or more participants, if the lesser of 500 participants or 10 percent of all participants are literate in the same non-English language)."(Davis Wright Tremaine LLP)

Federal Agencies Offer Safe Harbor on External Review Processes under PPACA
Excerpt:"Federal agencies have announced the availability of EBSA Technical Release No. 2010-01, which provides an interim enforcement safe harbor for non-grandfathered self-insured group health plans not subject to a State external review process, and therefore subject to the Federal external review process."(PLANSPONSOR.com)

[Guidance Overview] Failure to Substantially Comply with Claims Procedures Proves Costly to Health Plan
Excerpt:"The plan fiduciary's failure to follow the claims regulations had a surprisingly harsh effect on the outcome in this recent claim for benefits case. Neither the standard of review nor the contractual limitations period served to deflect an award of benefits, attorneys'fees and costs in favor of the claimant."(Roy Harmon via Health Plan Law)

Health Insurance Coverage and Birth Control
Excerpt:"More than half of America's employees work for companies with self-financed plans, which pay employees'health claims directly. Those plans are not bound by the state coverage requirements. Small-business and individual policies also tend to provide less comprehensive contraceptive coverage, experts note."(The New York Times; free registration required)

[Guidance Overview] Can Preexisting Condition Insurance Plans Help Employers Control Health Care Costs?
Excerpt:"An employer could be subject to sanctions if it offers financial incentives to enrolled individuals who end up in the [Preexisting Condition Insurance Plan]. Would the comparisons of eligibility periods and coverage costs be sufficient to constitute'disincentives'? The PCIP rules do not appear to preclude the employer from steering new employees to the program. Any reasons why it should not?"(Tax Management Inc.)

ObamaCare's Loss Ratio Rules Are Out of Balance, Critics Say
Excerpt:"Supporters say these new'medical loss ratio'regulations could provide better value for consumers. Critics argue that they could decrease innovation and competition."(Investor's Business Daily)

[Guidance Overview] Regulations Regarding Internal Claims and Appeals and External Review Processes
Excerpt:"The new claims and appeals requirements under health care reform will impose more time-consuming and expensive rules on plan administrators. Plan sponsors considering the benefits of retaining grandfathered status will want to carefully consider these costs. These additional costs may encourage employers to retain grandfathered status. However, in many cases, if an employer has multiple benefit options, only some of which may be grandfathered, it may make more sense to apply all of the new claims procedures to all applicable group health plans in order to make the process consistent for everyone."(Sherman&Howard)

New York State Requires Discussion on Options Before Breast Removal Surgery
Excerpt:"[A] state law signed on Sunday by Gov. David A. Paterson will require New York hospitals and doctors to discuss the options for breast reconstruction with their patients before performing cancer surgery, to give them information about insurance coverage and to refer them to another hospital, if necessary, for the reconstructive surgery."(The New York Times; free registration required)

What Are the Provisions in the New Health Law for Containing Costs and How Effective Will They Be?
Excerpt:"Policymakers are trying a wide array of approaches in an attempt to control costs, including competition among health plans, taxes on high-cost plans, delivery system and payment reforms, wellness programs, and controls over Medicare provider payments."(Urban Institute)

[Guidance Overview] Implementing Parity: The Safe Harbor for Outpatient Benefits (PDF)
2 pages. Excerpt:"A new reform briefing paper looks at the safe harbor for outpatient benefits and augments an earlier discussion about the steps group health plans face as they respond to the new rules."(Milliman)

[Guidance Overview] New Health Care Claims and Appeal Rules Will Include an Excise Tax
Excerpt:"In contrast to current rules, failure to comply with the Section 503 Regulations as modified by the new internal claims and appeals and external review processes requirements may subject a health plan sponsor or health insurance issuer to a $100 per day per violation excise tax imposed under the Internal Revenue Code, in addition to giving the claimant a green light to file suit."(Littler Mendelson P.C.)

[Opinion] Will Employers Undermine Health Care Reform by Dumping Sick Employees?
Excerpt:"This Essay argues that federal health care reform may induce employers to redesign their health plans to encourage employees who are likely to consume a greater-than-average amount of medical services to opt out of employer-provided coverage and instead acquire coverage on the individual market."(Social Science Research Network)

Electronic Medical Records: Higher Costs Cited by Study
Excerpt:"Contradicting conventional IT wisdom, a team of researchers has found that implementing electronic medical records results in higher costs, more staffing and more medical complications."(The Fiscal Times)

Health-Care Overhaul Nitty-Gritty: The Medical-Loss Ratio and Taxes
Excerpt:"[R]egulators are now wrestling with the medical-loss ratio -- what percentage of an insurer's revenue is dedicated to health-related expenses, versus administrative costs -- and into which bucket various kinds of costs should fall."(The Wall Street Journal)

[Guidance Overview] Internal and External Claims Review Guidance for Non-Grandfathered Health Plans (PDF)
6 pages. (Buck Consultants)

[Guidance Overview] HIPAA Isn't a Shield Against Third-Party Payor Audits
Excerpt:"A frequent question of physicians, medical practices and other providers I represent is whether the HIPAA Privacy Rule prohibits them from providing third-party payors with access to medical records for the purposes of an audit."(Warner Norcross&Judd LLP)

Avoidable Medical Errors Cost $19.5 Billion Annually
Excerpt:"A new study commissioned by the Society of Actuaries looks at the cost of avoidable medical mistakes and quantifies the economic impact of such mistakes as $19.5 billion annually."(Healthcare Town Hall via Milliman)

[Opinion] Group Letter to HHS in Support of Health Information Technology and Quality Initiatives (PDF)
3 pages. (American Benefits Council)

One of Health Care's Remaining Frontiers: Health Information Exchange
Excerpt:"The 2009 stimulus bill will direct billions of dollars to doctors and hospitals that adopt health information technology, and more to set up health information exchanges that would attempt to take on this problem . . . ."(Henry J. Kaiser Family Foundation)

[Guidance Overview] New Internal and External Claims Procedures for Group Health Plans
Excerpt:"The new rule explicitly requires the plan or issuer to provide continued coverage pending the outcome of the appeal. As under the current regulations, advance notice and an opportunity for an advance review must be provided before benefits for an ongoing course of treatment can be reduced or terminated."(Deloitte via BenefitsLink.com)

[Opinion] Coherent and Transparent Health Care Payment: Sending the Right Signals in the Marketplace
Excerpt:"Global Fees. The current fee-for-service payment system rewards physicians for providing a greater volume of more costly services rather than for getting the best results for patients. An alternative is to pay each provider organization a global fee for all care -- a fixed, per-person payment based on the patient's health condition or a risk-adjusted capitation rate."(The Commonwealth Fund)

[Guidance Overview] New Regulations for Preventive Services and Appeals Processes Under Health Reform
Excerpt:"Language Requirements for Notices. A plan or issuer is considered to provide the notices in a culturally and linguistically appropriate manner if: In the case of a plan that covers fewer than 100 participants at the beginning of the year, and 25% or more of the participants are literate only in the same non-English language, the notice is provided in that language. In the case of a plan that covers 100 or more participants at the beginning of the year, and the lesser of 500 participants or 10% or more of the participants are literate only in the same non-English language, the notice is provided in that language."(Troutman Sanders LLP)

[Opinion] Will Employers Undermine Health Care Reform by Dumping Sick Employees?
Excerpt:"This Essay argues that federal health care reform may induce employers to redesign their health plans to encourage employees who are likely to consume a greater-than-average amount of medical services to opt out of employer-provided coverage and instead acquire coverage on the individual market."(Social Science Research Network)