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Hospitals are still resisting transparency, and reacting in unconstructive ways to reference-based pricing. The evidence shows many health care providers have some way to go in embracing changes designed to repair our nation’s cost spiral. We in the self-funding industry can make a difference, and at the same time protect our plan members from unfair […]
By Bruce Roffé Businesses sponsoring self-insured health plans are desperately seeking ways to reduce health care costs, and it’s no secret prescription drugs make up a significant chunk of those costs. If you look more closely, specialty drugs emerge as a main culprit. These high-cost meds made up less than one percent of all written […]
A prescription drug’s ability to prolong life is a top factor health plans are using when fixing benchmark prices for drug reimbursement, followed by the drug’s ability to improve the patient’s quality of life, health care stakeholders said at an April 15 briefing hosted by the Alliance for Health Reform. Steven Pearson, MD, MSc, president […]
A federal district court in Pennsylvania denied a large part of US Airways’ attempted recovery from the estate of plan participant James McCutchen, citing inconsistencies between the company’s plan document and summary plan description. If a plan’s official plan document states that its language trumps that of the SPD, the plan should not assert rights […]
In order for reference-based pricing to work, health plan sponsors should do it in a way that involves implementing best practices for cost analysis, claim repricing, plan design, patient advocacy (including balance billing protection when necessary), and member education. Ways to Make RBP Succeed Employers, administrators, brokers and courts have begun to realize that determining the value […]
Monitoring the performance of service providers, making required disclosures to participants and beneficiaries, keeping good records and filing reports with the government are just a few of the important functions a fiduciary must ensure are properly executed, an enforcement official at the U.S. Department of Labor’s Employee Benefits Security Administration unit told a group of […]
Employers will have 60 more days to send notices to participants and beneficiaries, and about 90 more days to send notices to the IRS about health coverage offered and employees’ health coverage status, the IRS announced Dec. 28. IRS Notice 2016-4 extends the due dates of the information reporting requirements for insurers, self-insuring employers and […]
Employers that purchase small group coverage that is federally regulated under the Affordable Care Act will have additional assurances that their plan members will not be balance billed in certain situations, under proposed rules issued in pre-publication form on Nov. 22. The rule also plans for the adoption of network adequacy provisions to compensate for […]
U.S. Supreme Court Justices questioned parties in a case that could further clarify when an ERISA plan fiduciary can recover settlement funds that a plan participant or beneficiary once acquired in a personal injury action but no longer possesses. This case involving the scope of equitable relief under ERISA has significant implications for plans that […]
On Oct. 7, 2015, President Obama signed, without comment, the Protecting Affordable Coverage for Employees Act, which amends the Affordable Care Act’s definition of a “small-group,” a move intended to force mid-sized companies into providing richer coverage to workers. The PACE Act (H.R. 1624 and S. 1099) repeals the mandatory expansion of the small group […]