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 contain costs and improve the quality of health care. 2009-11-21T13:38:04Z http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Political-maneuvering-misses-the-point-on-rising-c/ArticleStandard/Article/detail/638748?contextCategoryId=2885&ref=25 Few are paying attention to the cost curve and the potential for state to enact their own reform measures 2009-11-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/452009/638748null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Silent-PPOs-under-scrutiny/ArticleStandard/Article/detail/630641?contextCategoryId=2885&ref=25 Model legislation adopted by NCOIL provides that the third party accessing the contract must comply with contacting terms 2009-10-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/402009/630641null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Employer-mandated-spending-requirement-challenged/ArticleStandard/Article/detail/615497?contextCategoryId=2885&ref=25 The Golden Gate Restaurant Association argues that contributions to San Francisco's Health Access Program under a 2006 ordinance are preempted by ERISA 2009-08-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/312009/615497null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/False-Claims-Act-expanded-under-FERA/ArticleStandard/Article/detail/607980?contextCategoryId=2885&ref=25 Significant changes extend liability and add a new definition of the word 'obligation' for reverse false claims. 2009-07-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/272009/607980null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Mental-health-legislation-in-effect-for-most-in-20/ArticleStandard/Article/detail/601160?contextCategoryId=2885&ref=25 Financial considerations, treatment offerings and networks must be comparable to medical benefits 2009-06-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/232009/601160null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Healthcare-acts-signed-into-law/ArticleStandard/Article/detail/590437?contextCategoryId=2885&ref=25 The reinvestment act contains more than $100 billion in federal funding for healthcare initiatives 2009-04-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/142009/590437null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Democrats-frustrated-with-Part-D-plan-oversight/ArticleStandard/Article/detail/584936?contextCategoryId=2885&ref=25 Sponsors of Part D legislation believe private Medicare Part D plans have been less effective than the government could be in negotiating price concessions. 2009-03-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/102009/584936null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/CBO-examines-more-than-100-proposals/ArticleStandard/Article/detail/577627?contextCategoryId=2885&ref=25 Pick your poison. Even with the grand number of proposals on the table, healthcare will still cost the nation trillions. 2009-02-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/052009/577627null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Expect-tighter-solvency-control/ArticleStandard/Article/detail/577628?contextCategoryId=2885&ref=25 Measurement tools used by state regulatory bodies evaluate MCO capitalization and investment 2009-02-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/052009/577628null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Broker-compensation-rules-tighten/ArticleStandard/Article/detail/573822?contextCategoryId=2885&ref=25 Brokers can no longer churn enrollees from plan to plan just to gain extra commission checks 2009-01-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/022009/573822null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Economy-causes-greater-scrutiny-of-insurers/ArticleStandard/Article/detail/569623?contextCategoryId=2885&ref=25 In the midst of current financial turmoil, the industry entrusted with the greatest accumulation of funds is the insurance industry. MCOs and HMOs should expect greater scrutiny of their finances. 2008-12-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/492008/569623null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/HIPAA-compliance-must-address-organization-oversig/ArticleStandard/Article/detail/562102?contextCategoryId=2885&ref=25 HHS is giving HIPAA enforcement efforts more teeth with fees and Corrective Action Plans 2008-11-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/442008/562102null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Support-expands-for-never-events-policies/ArticleStandard/Article/detail/547906?contextCategoryId=2885&ref=25 More than three years after Minnesota-based HealthPartners drew national attention after stating it would no longer pay hospitals for costs of treatment related to never events Medicare and private health plans are jumping on the never-event bandwagon. 2008-09-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/362008/547906null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Congress-considers-sweeping-changes-to-False-Claim/ArticleStandard/Article/detail/533521?contextCategoryId=2885&ref=25 The civil False Claims Act is the principal weapon in the government's arsenal to combat healthcare fraud. The Senate and the House are considering bills that would further expand the scope of liability under the Act and eliminate two of the key defenses to meritless lawsuits filed by qui tam plaintiffs. 2008-08-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/322008/533521null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/States-decide-business-of-insurance/ArticleStandard/Article/detail/528021?contextCategoryId=2885&ref=25 Capitation and other risk-sharing arrangements have been pursued by provider organizations for the past two decades. Yet the law on whether such arrangements result in the provider organization being in the business of insurance has not fully evolved in all states. 2008-07-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/272008/528021null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Understand-Public-Information-Act-to-protect-recor/ArticleStandard/Article/detail/522494?contextCategoryId=2885&ref=25 When companies interact with governmental bodies, issues related to the Public Information Act frequently arise. It is imperative for those companies to understand the Public Information Act as well as the internal procedures that may be developed to handle open records issues. 2008-06-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/242008/522494null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Captive-insurance-arrangements-more-common/ArticleStandard/Article/detail/515151?contextCategoryId=2885&ref=25 Many healthcare entities have explored certain alternative risk transfer arrangements as a means for insuring, or perhaps self-insuring, various exposures. The use of captive insurance arrangements has been a common approach, and thus, "protected cell companies" have become popular vehicles. 2008-05-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/192008/515151null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/States-face-ERISA-hurdle-on-employer-funded-univer/ArticleStandard/Article/detail/500099?contextCategoryId=2885&ref=25 Across the country, state and local lawmakers are discussing various mechanisms to provide healthcare coverage to uninsured residents, and some states have recently enacted such legislation. Some of these laws include the requirement to make employers fund at least part of the states' health insurance programs. 2008-03-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/102008/500099null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Proposed-HIPSA-Legislation-Intends-to-Tighten-Priv/ArticleStandard/Article/detail/482407?contextCategoryId=2885&ref=25 Sens. Leahy and Kennedy have introduced the Health Information Privacy and Security Act of 2007 (HIPSA), which if enacted into law, would require HHS to revise HIPAA. 2008-01-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/022008/482407null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Understand-choice-implications-of-law-principles/ArticleStandard/Article/detail/476116?contextCategoryId=2885&ref=25 Choice of law issues arising from coverage disputes of both individual and group insurance policies many times determine which party will prevail on the merits of a particular case. Also, in today's mobile economy, insurance transactions frequently cross state boundaries. 2007-12-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/482007/476116null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Monitor-discrimination-laws-for-wellness-programs/ArticleStandard/Article/detail/469644?contextCategoryId=2885&ref=25 As employers search for ways to reduce rising healthcare costs and improve employee productivity, more companies are implementing wellness programs in an attempt to improve employees' health and reduce their own insurance costs. There are a number of different options employers may consider when deciding to institute a wellness program, including offering smoking cessation and weight loss programs, fitness classes, and in some cases, penalizing certain behavior. Employers must be careful, however, to ensure that these programs do not violate certain federal and state laws as they carry certain inherent legal risks. 2007-11-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/442007/469644null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Prepare-for-inevitable-underwriting-challenges/ArticleStandard/Article/detail/462215?contextCategoryId=2885&ref=25 There are as many as 75 million Americans who are either uninsured or underinsured, and the rate will continue to grow. Access to healthcare for all Americans was a hot topic during the early years of the Clinton administration, and has resurfaced recently in anticipation of the 2008 presidential election. 2007-10-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/402007/462215null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Corrective-action-plans-play-integral-role-in-Medi/ArticleStandard/Article/detail/446459?contextCategoryId=2885&ref=25 Ahearing before a federal district court this summer will most likely conclude the 14-year Texas class action case of Frew v. Hawkins. This class action suit was filed in 1993 by a group of mothers who were dissatisfied with the medical treatment that their children received—children who qualified for, but allegedly did not receive, full preventive care and treatment under Medicaid laws. As states enact changes to ensure full compliance with these laws, MCOs will see the effects on Medicaid provider networks, reimbursement rates and reporting requirements. 2007-08-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/312007/446459null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Rescission-practices-can-protect-against-misrepres/ArticleStandard/Article/detail/439157?contextCategoryId=2885&ref=25 The practices of some California insurers have recently come under attack in lawsuits brought by private litigants and in administrative actions brought by state regulators. The practice involves the rescission of health insurance policies due to misrepresentations made in the policy application form. 2007-07-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/272007/439157null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Courts-split-on-assignment-of-benefit-laws-Insurer/ArticleStandard/Article/detail/433323?contextCategoryId=2885&ref=25 An assignment of benefits is a transfer of an insured's interest in policy benefits to another party. The policy generally requires a written assignment by the insured to the provider, allowing the provider to bill the health plan directly. Such an assignment results in the payment of medical benefits directly to the healthcare provider rather than to the insured. 2007-06-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/242007/433323null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/HMO-solvency-protected-by-insurance-company-holdin/ArticleStandard/Article/detail/424946?contextCategoryId=2885&ref=25 At present, most states have made HMOs subject to their insurance holding company acts. Insurance holding company acts are comprehensive bodies of law that govern the relationships and activities within insurance holding company structures. These laws indirectly regulate the activities of entities that are affiliated with insurance companies and HMOs, which would not otherwise be subject to regulation. 2007-05-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/192007/424946null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Deficit-Reduction-Act-allows-reinvention-of-Medica/ArticleStandard/Article/detail/415865?contextCategoryId=2885&ref=25 As healthcare costs continue to spiral out of control, state officials across the country are pursuing creative ways to control the high costs of Medicaid services for low-income women, children, the disabled and the elderly. 2007-04-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/142007/415865null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Corporate-practice-of-medicine-seen-as-ancient-app/ArticleStandard/Article/detail/409179?contextCategoryId=2885&ref=25 The Illinois Supreme Court recently confirmed that the corporate practice of medicine doctrine is still alive and well in the state of Illinois. In Vine Street Clinic, et al. v. HealthLink Inc., the court concluded that percentage-based fees charged by the owner of a healthcare provider network were illegal under the state's medical practices act. 2007-03-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/102007/409179null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/False-Claims-Act-proves-difficult-to-fight/ArticleStandard/Article/detail/401867?contextCategoryId=2885&ref=25 The federal False Claims Act (FCA) is the government's primary weapon to combat fraud. It empowers the federal government to file actions against those alleged to have knowingly submitted false or fraudulent claims to the government. Since 1986, the Department of Justice has recovered more than $15 billion under the law. 2007-02-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/052007/401867null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Anticompetitive-activities-may-not-give-rise-to-an/ArticleStandard/Article/detail/396680?contextCategoryId=2885&ref=25 The Supreme Court has referred to U.S. antitrust laws as the Magna Carta of free enterprise—a set of laws as important to the preservation of economic freedom as the Bill of Rights is to the protection of personal freedoms. While these laws are typically enforced by state and federal governments, i.e., the Department of Justice and state attorneys general, they also provide for a private right of action enforceable by persons who have been injured by activities that are forbidden by the antitrust laws. 2007-01-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/022007/396680null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Solvency-regulation-helps-minimize-economic-failur/ArticleStandard/Article/detail/389258?contextCategoryId=2885&ref=25 Health insurance is one of the most regulated industries in the world. Within its comprehensive regulatory scheme, there are several laws that are designed to assure the solvency of health insurance companies and HMOs. These laws limit and restrict the types of investments that these companies may own, dictate the level of capitalization they must maintain, and establish other solvency measures. 2006-12-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/482006/389258null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Research-all-costs-before-seeking-fronting-arrange/ArticleStandard/Article/detail/383207?contextCategoryId=2885&ref=25 Insurance fronting arrangements are more commonly utilized in the property and casualty industry. However, MCOs also have uses for these structures in certain circumstances. For example, many HMOs discover that they have a need to offer products on insurance paper (PPO plans) but do not have the resources to form a separate insurance company. Or, a provider organization may ask an HMO to front for it with respect to a particular product line or sector. 2006-11-01T05:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/442006/383207null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Certain-regulatory-issues-surround-P4P-programs/ArticleStandard/Article/detail/367914?contextCategoryId=2885&ref=25 As CMS has begun to promote its quality agenda through pay-for-performance (P4P) initiatives, private payers should consider certain regulatory issues in establishing such programs. 2006-09-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/352006/367914null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Should-providers-fees-top-out-at-the-usual-and-cus/ArticleStandard/Article/detail/363955?contextCategoryId=2885&ref=25 An ongoing issue among insurers is how to determine "usual and customary" (U&C) charges for medically necessary services that are provided by out-of-network providers. While some state laws require an insurer to pay U&C charges, there often is limited guidance as to how to calculate those charges. Case law from various jurisdictions, as well as several treatises, suggest that U&C may be based on the prevailing rates for similar services in the community and that actual charges billed by the provider are not determinative. 2006-08-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/322006/363955null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Health-plans-third-party-recovery-provisions-may-n/ArticleStandard/Article/detail/357672?contextCategoryId=2885&ref=25 In a unanimous decision (Sereboff v. Mid-Atlantic Med. Svcs.) released on May 15, 2006, the U.S. Supreme Court permitted a health insurer to enforce a reimbursement provision against a participant. The plan had paid approximately $75,000 for the treatment of injuries suffered by the participant, Marlene Sereboff, and her spouse, who subsequently received $750,000 pursuant to a third-party tort settlement. The health plan provided that a participant who is injured by another person and receives benefits under the plan for such injuries must reimburse the plan from any amount recovered, without reduction, for failure to receive the full damages claimed. When the participant refused to comply with this reimbursement provision, the insurer obtained an injunction requiring the Sereboffs to set aside sufficient funds from the settlement, pending a final ruling in the case. 2006-07-01T04:00:00Z http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/282006/357672null XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Be-mindful-of-the-contract-in-silent-PPO-arrangeme/ArticleStandard/Article/detail/329908?contextCategoryId=2885&ref=25 At present, laws in 14 states are designed to prohibit the use of silent discount arrangements and intended to eliminate so-called "silent PPOs," "ghost PPOs," or "blind PPOs," all of which refer to the same thing. 2006-06-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Blogs-Inappropriate-at-work-a-protected-right-for-/ArticleStandard/Article/detail/322940?contextCategoryId=2885&ref=25 Blogs: Inappropriate at work, a protected right for employees 2006-05-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Reinsurance-is-an-integral-part-of-risk-management/ArticleStandard/Article/detail/314985?contextCategoryId=2885&ref=25 Reinsurance is often called "insurance for insurers." It involves a contract whereby one insurer (the reinsurer) agrees, for a portion of the premium, to indemnify another insurer (the ceding company or primary insurer) for losses paid by the ceding company under insurance policies it has issued to its policyholders. Notwithstanding the heavy regulation of insurance and the products that are issued by primary insurers, reinsurance is largely an unregulated business. 2006-04-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Assumption-reinsurance-getting-the-bad-along-with-/ArticleStandard/Article/detail/311727?contextCategoryId=2885&ref=25 When health insurers buy an existing book of business, they often effect the acquisition through an asset purchase transaction known as assumption reinsurance. There are many accounting and financial issues to consider in pursuing such a transaction. 2006-03-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/HMO-regulations-aim-to-protect-but-can-burden-buye/ArticleStandard/Article/detail/301713?contextCategoryId=2885&ref=25 Employers and other purchasers of health insurance continue to face rising costs for employee health benefits. The overall cost of providing such benefits has reached such a high level that employers are now often requiring their employees to share part of this burden. 2006-02-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Soft-approach-required-for-marketing-Medicare-drug/ArticleStandard/Article/detail/282709?contextCategoryId=2885&ref=25 The Medicare Advantage unit within the Centers for Medicare and Medicaid Services (CMS) is keeping a watchful eye on improper marketing activities in the new, revamped Medicare product market. Medicare officials at CMS have received numerous complaints about the aggressive sales tactics being used by some insurance agents and insurers in the marketing of new Medicare prescription drug plans. 2006-01-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Federal-government-can-question-reverse-mergers/ArticleStandard/Article/detail/256155?contextCategoryId=2885&ref=25 In January 2000, three hospitals located in or around Chicago merged to form a single hospital health system. More than four years later, the Federal Trade Commission (FTC) sued to unwind the merger, claiming that it caused substantially higher prices to consumers. On October 20, 2005, an administrative law judge (ALJ) sided with the FTC and ordered the merger unwound. 2005-12-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Reforms-fuel-efforts-to-increase-awareness-of-cove/ArticleStandard/Article/detail/196471?contextCategoryId=2885&ref=25 In today's world, health insurance is a necessity for sound financial planning.With medical expenses soaring, lack of insurance could prove financially ruinous. Moreover, the uninsured population faces a greater mortality risk than adults with coverage. According to a recent census report, 45 million Americans do not have health insurance—almost one in five. Studies have shown that cost is the primary reason for the lack of coverage. 2005-11-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Make-certain-to-carry-out-the-charge-of-managing-c/ArticleStandard/Article/detail/183306?contextCategoryId=2885&ref=25 In a case that likely will be appealed, a San Antonio jury recently awarded $7.4 million in actual damages resulting from the alleged negligence by a health maintenance organization and several providers. In the lawsuit, a deceased woman's family accused Humana, two physicians, and a physician practice group of negligence in a wrongful death action. The jury decision resulted from a three-week trial presided over by a Republican-appointed judge with an insurance defense background. In accordance with Texas law requiring the apportionment of liability, the jury found Humana liable for 35% of the actual damages and the entire $1.6 million in punitive damages. 2005-10-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Balance-billing-by-facility-providers-requires-a-s/ArticleStandard/Article/detail/178277?contextCategoryId=2885&ref=25 In Some Parts of the United States, health plans have observed a growing trend of hospital-based provider groups, such as radiologists, pathologists, anesthesiologists, and emergency room physicians refusing to contract with health benefit plans. When a health plan enrollee seeks services from an in-network hospital in order to obtain lower out-of-pocket costs (for a PPO product) or full benefits (for an HMO product), the enrollee can be hit with a large, unexpected bill from the provider. 2005-09-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Managed-care-experiments-with-new-Medicaid-model/ArticleStandard/Article/detail/170532?contextCategoryId=2885&ref=25 The majority Of the funding for Medicaid comes from the federal government, while the administration for the program is performed largely by the states. 2005-07-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Medicare-appeals-process-gets-overhaul/ArticleStandard/Article/detail/164168?contextCategoryId=2885&ref=25 Providers may want to be aware of changes published by the Center for Medicare and Medicaid Services (CMS) that substantially overhaul the appeals process, in part, to reduce the time frames for adjudicating fee-for-service Medicare claims appeals. A process that now exceeds 1,000 days must be reduced to 300 days. 2005-06-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Material-differences-exist-in-HMO-vs-Insurer-regul/ArticleStandard/Article/detail/159383?contextCategoryId=2885&ref=25 In the early-to-mid 1990s, employers began choosing HMO products over PPOs and traditional health insurance plans because of cost concerns. 2005-05-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Texas-wrangling-employer-costs-for-workers-comp-in/ArticleStandard/Article/detail/155750?contextCategoryId=2885&ref=25 When worker's compensation laws were first adopted in the early part of the 20th century, they were promoted as a revolutionary advancement of employees' rights. 2005-04-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/States-have-limited-role-in-regulating-MA-organiza/ArticleStandard/Article/detail/150894?contextCategoryId=2885&ref=25 LAST FALL, THE CENTERS for Medicare and Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC), published a memorandum providing guidance to state regulators regarding the licensure and regulation of Medicare Advantage (MA) organizations. 2005-03-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Complete-information-critical-to-new-managed-care-/ArticleStandard/Article/detail/146110?contextCategoryId=2885&ref=25 Recent Acquisitions of companies specializing in consumer-driven health plans (CDHPs) may lead to further product innovation and competition in the managed care market. 2005-02-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Regulatory-limitations-impact-annual-financial-dec/ArticleStandard/Article/detail/141941?contextCategoryId=2885&ref=25 We are approaching the time of year when health insurers are beginning to calculate loss ratios and compile other financial data in order to evaluate the performance of their book of business. They will evaluate each market segment and product line, and make underwriting and rating decisions as to each. 2005-01-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Broker-contingent-commissions-scrutinized/ArticleStandard/Article/detail/136681?contextCategoryId=2885&ref=25 New York Attorney General Eliot Spitzer recently pursued investigations focused on a common industry practice utilized by insurers and the brokers that represent corporate buyers of commercial insurance. At issue is whether bids are being rigged, prices fixed, and whether brokers are steering business to insurers that pay them the highest fees without getting the best deal for their corporate clients. 2004-12-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Non-profit-insurers-follow-the-conversion-trend/ArticleStandard/Article/detail/133402?contextCategoryId=2885&ref=25 For the past several years, non-profit health plans and insurers have been converting to for-profit corporations (or have been acquired by for-profit enterprises) in an effort to gain access to capital markets, to expand their service area, and/or to add to their product lines. In most states, the Blue Cross Blue Shield plans are no longer non-profit. 2004-11-01T05:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/FTC-and-DOJ-encourage-industry-competition/ArticleStandard/Article/detail/128712?contextCategoryId=2885&ref=25 On July 23, a joint report on the role of competition in healthcare was issued by the Federal Trade Commission and the Department of Justice. Covering a range of issues dealing with the cost, quality and accessibility of healthcare, the report was produced as the result of a two-year project conducted by the two agencies, which included over five weeks of joint hearings held in 2003. 2004-10-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/HMOs-have-options-in-asset-sales-but-transactions-/ArticleStandard/Article/detail/121933?contextCategoryId=2885&ref=25 An asset sale by an insurance company or a health maintenance organization typically involves the transfer of a block of business and generally is accomplished by an "assumption" or "portfolio" reinsurance transaction (when risk is transferred from one insurer to another) covering part or all of the seller's existing business. 2004-09-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Industry-protected-under-ERISA-as-Texas-state-law-/ArticleStandard/Article/detail/109137?contextCategoryId=2885&ref=25 On June 21, a unanimous U.S. Supreme Court held that state law is completely pre-empted by the Employee Retirement Income Security Act (ERISA)of 1974 with respect to disputes over denial of benefits under ERISA-regulated health benefit plans. The Court's ruling appears to insulate managed care organizations from punitive and extra-contractual damages related to denial of benefits. In its decision, the Court overruled two lower court rulings. 2004-08-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Recent-acquisition-fixation-requires-regulatory-gu/ArticleStandard/Article/detail/105559?contextCategoryId=2885&ref=25 In the first half of this year, there have been several significant business transactions in the managed care industry that have either been completed or announced. Just to name a few, Anthem and WellPoint Health Networks are merging; UnitedHealthcare acquired Mid-Atlantic Medical Services; Humana acquired Ochsner Health Plan; UnitedHealthcare announced the acquisition of Oxford Health Plans; and Molina Healthcare announced its acquisition of Cimarron Health Plan. In this highly regulated industry, these types of transactions require various regulatory approvals. With so much activity this year, it is important to highlight some of the necessary procedures for potential acquirers and targets. 2004-07-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Impact-of-the-Maine-PBM-disclosure-law-not-yet-kno/ArticleStandard/Article/detail/100666?contextCategoryId=2885&ref=25 Court's decision shows that increasing transparency might decrease PBMs' ability to compete 2004-06-01T04:00:00Z XML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Federal-court-OKs-FCA-prosecution-of-improper-seco/ArticleStandard/Article/detail/96832?contextCategoryId=2885&ref=25 U.S. joins the suit against Highmark in false Medicare claims case 2004-05-01T04:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Commentary/Subcontractor-relationships-scrutinized-under-publ/ArticleStandard/Article/detail/89088?contextCategoryId=2885&ref=25 Financial affairs between a health plan and federal subcontractors requires continuous review 2004-03-01T05:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Most-favored-nation-clauses-can-create-antitrust-l/ArticleStandard/Article/detail/85871?contextCategoryId=2885&ref=25 Loss of potential competition is a loss of consumer welfare under antitrust laws 2004-02-01T05:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Whats-in-your-arbitration-agreement/ArticleStandard/Article/detail/82724?contextCategoryId=2885&ref=25 MCOs should word arbitration clauses as carefully as the rest of the contract 2004-01-01T05:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Health-plan-liability-in-the-hands-of-the-Supreme-/ArticleStandard/Article/detail/78465?contextCategoryId=2885&ref=25 Outcome of ERISA interpretation will affect care management programs including drug utilization review 2003-12-01T05:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Legality-of-Californias-pay-or-play-law-called-int/ArticleStandard/Article/detail/75650?contextCategoryId=2885&ref=25 Uninsured workers need coverage, but opponeents say law is preemted by ERISA 2003-11-01T05:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Cases-alleging-negligent-plan-design-can-survive-E/ArticleStandard/Article/detail/72527?contextCategoryId=2885&ref=25 Policies governing controversial or experimental modalities need to be in tune with best practices 2003-10-01T04:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Commentary/State-legislature-weigh-in-on-behalf-of-providers/ArticleStandard/Article/detail/69438?contextCategoryId=2885&ref=25 Slew of recent lawsuits impact states' awareness of unfair practice allegations 2003-09-01T04:00:00Z HTML http://managedhealthcareexecutive.modernmedicine.com/mhe/Letter+of+the+Law/Health-plan-has-no-duty-to-disclose-physician-ince/ArticleStandard/Article/detail/66368?contextCategoryId=2885&ref=25 Points to consider with plan beneficiaries and physician compensation arrangements 2003-08-01T04:00:00Z HTML