How much insurance do you really need? Next to food and housing, insurance is most Americans' biggest expense, says financial expert Jonathan D. Pond, author of Grow Your Money--"and a single gap in coverage can wipe out decades of hard-earned savings." As crucial as insurance is, though, you can save a bundle once you learn how to separate the essential from the extraneous.(Buying & Saving) - Quick & Simple

[ILLUSTRATIONS OMITTED]

yes

Health Insurance

Do you need it? YES. Even if you can't remember the last time you came down with a cold, that doesn't mean you're bulletproof. Health insurance guarantees you won't wind up drowning in medical debt after an unexpected illness or injury.

Consider:

* Temporary insurance: Being between jobs is no excuse for going without coverage. 'Forty dollars a month can get you a policy that lasts six months, and can be renewed three times,' says Peter Bielagus, author of Getting Loaded: Make a Million While You're Still Young Enough to Enjoy It. (Two companies offering good temporary policies are Anthem Blue Cross/Blue Shield and Assurant, he notes.) Under the COBRA law, you can also remain enrolled in your former employer's group plan for 18 months (visit cobrainsurance.com for details).

* Limited benefit plans: If your family's medical expenses tend to be minimal, these are a good bet--their premiums are roughly 80 percent lower than those charged by traditional plans. Be advised, though, that some are a bit too 'bare bones,' compensating you only for doctors' appointments and prescription drugs. You're best off with a plan that also covers emergency room visits and hospitalization. (Look into Century Healthcare's limited benefit plans at centuryhealthcare.com.)

* High deductible plans: If you're young and healthy, go for it. Your monthly payments will be quite low, but remember, says Bielagus, 'a high deductible means that you take on more of the risk.'

no

Pet Insurance

Do you need it? NO. Most vets offer flexible payment schedules, and some even consider their fees negotiable, says Pond.

Consider:

* A flat-rate plan: If you're the type who will do virtually anything for Fluffy, look for a plan with a flat, published premium rather than a rate that fluctuates based on a pet's age or breed. And note that many companies won't cover pets older than 10.

maybe

Life Insurance

Do you need it? MAYBE. If you're single and childless, or your kids are grown, you can opt out. But if you have dependents who count on your steady income, consider it.

Consider:

* Term coverage: Look for a policy that protects you for a fixed period of time (typically 5 to 20 years) and is payable upon the holder's death. Cash value insurance--which increases in value over time but allows benefits to be paid out before you die--is expensive, and only worth considering if you expect to be supporting a dependent for the rest of his or her life.

* Disability insurance: Before buying life insurance, make sure you have this. Your chances of suffering a disability during your lifetime are 1 in 4, and you're 7 times more likely to become disabled before the age of 65 than you are to die. A decent policy costs between $100 and $200 a year through most employers, and inexpensive coverage is also available through your local Chamber of Commerce.

yes

Homeowners Insurance

Do you need it? YES. You never know when the next wildfire or tropical storm could hit, destroying your most valuable asset. Consider:

* Replacement cost coverage: If your TV is totaled, you want to be reimbursed for the cost of a brand-new one, not for the cash value of the one you bought five years ago!

* Flood damage: It's not covered by your standard homeowners policy. 'Many people assume if their bank doesn't require them to buy flood insurance, they don't need it,' says Carolyn Gorman, vice president of the Insurance Information Institute. But that's simply not the case--and a full 90 percent of natural disasters in the U.S. involve some type of flooding!

* Renters insurance: If your belongings have been stolen or destroyed, your landlord probably won't cover the replacement costs. 'Renters insurance is actually extremely affordable, roughly $15 to $20 a month,' says Bielagus.

yes

Auto Insurance

Do you need it? YES. Not only is it required by law, but the Department of Transportation documented nearly 6 million motor vehicle accidents last year.

Consider:

* Uninsured and underinsured motorist coverage: It protects you if you sustain an injury in an accident for which an uninsured driver is at fault--and believe it or not, one in seven drivers is uninsured! While your health insurance should cover your medical bills, the additional coverage means you're also compensated for lost wages, as well as pain and suffering.

* Comprehensive and collision insurance: If your 8-year-old Honda has seen better days, you probably don't need it. Your insurer doesn't value your old vehicle, so even if it's demolished, you won't get a big payout. But if you have a new car or are still paying off a loan, it's a must!

* Asking for discounts: You may be eligible through your employer or professional organization, but you can also qualify for a cut if you've been accident- or violation-free for several years.

>q&s tip

BestWeek: Insurers, Regulators Have Questions After Oral Arguments in PPACA Case. - Health & Beauty Close-Up

Now that the U.S. Supreme Court has finished hearing oral arguments in the closely watched health care reform case, the industry is wondering how the high court's decision might affect the new status quo that has emerged since the law went into effect in 2010, according to the latest issue of BestWeek U.S./Canada.

The Company said the justices are expected to issue a ruling in U.S. Department of Health and Human Services v. Florida in June. Insurers, their brokers and regulators have many questions-particularly on the issue of how those with pre-existing conditions will be covered.

According to a release, through the Patient Protection and Affordable Care Act, Congress sought to address that problem by creating a mandate requiring all Americans to obtain health insurance or face a financial penalty. The thinking was if more healthy people were required to enter the risk pool, they would help to offset the increased risk associated with pre-existing condition consumers and to lower health insurance premiums. Three days of video coverage are included in the package.

In BestWeek Europe, European life insurers are being forced to adjust their business plans and capital management strategies in response to the eurozone credit crisis and regulatory changes including Solvency II, according to a new market review from A.M. Best Europe - Rating Service.

Also in BestWeek U.S./Canada, under fire for being too profitable and charging unreasonable rates, lender-placed insurance has been hit with a flurry of consumer complaints and several federal lawsuits.

Proponents say there would be no mortgages without an insurance safety net and rates higher than voluntary insurance reflect the broad risk that's insured without companies ever seeing the property, BestWeek said.

Gene Mergelmeyer, president and chief executive officer of Assurant Speciality Property, told BestWeek lender-placed insurance policies don't go through an underwriting process because they aren't individually written. He said his company contracts with lenders to insure all uninsured properties in the lender's portfolio.

'Literally on all the lapsed properties; without underwriting, without inspection, without knowing the property's condition or whether anyone is even living there,' Mergelmeyer said.

BestWeek is published by A.M. Best Co. for insurance professionals.

More information:

ambest.com/sales/BestWeek

BestWeek: After Oral Arguments Questions Remain for Insurers, Regulators - Manufacturing Close-Up

Now that the U.S. Supreme Court has finished hearing oralarguments in the closely watched health care reform case, theindustry is wondering how the high court's decision might affect thenew status quo that has emerged since the law went into effect in2010, according to the latest issue of BestWeek U.S./Canada.

In a release, the group noted:

the justices are expected to issue a ruling in U.S. Department ofHealth and Human Services v. Florida in June. Insurers, theirbrokers and regulators have many questions-particularly on the issueof how those with pre-existing conditions will be covered.

The research reported that through the Patient Protection andAffordable Care Act, Congress sought to address that problem bycreating a mandate requiring all Americans to obtain healthinsurance or face a financial penalty. The thinking was if morehealthy people were required to enter the risk pool, they would helpto offset the increased risk associated with pre-existing conditionconsumers and to lower health insurance premiums. Three days ofvideo coverage are included in the package.

In BestWeek Europe, European life insurers are being forced toadjust their business plans and capital management strategies inresponse to the eurozone credit crisis and regulatory changesincluding Solvency II, according to a new market review from A.M.Best Europe - Rating Service Ltd.

Also in BestWeek U.S./Canada, under fire for being too profitableand charging unreasonable rates, lender-placed insurance has beenhit with a flurry of consumer complaints and several federallawsuits.

Proponents say there would be no mortgages without an insurancesafety net and rates higher than voluntary insurance reflect thebroad risk that's insured without companies ever seeing theproperty, BestWeek said.

Gene Mergelmeyer, president and chief executive officer ofAssurant Speciality Property, told BestWeek lender-placed insurancepolicies don't go through an underwriting process because theyaren't individually written. He said his company contracts withlenders to insure all uninsured properties in the lender'sportfolio.

'Literally on all the lapsed properties; without underwriting,without inspection, without knowing the property's condition orwhether anyone is even living there,' Mergelmeyer said.

BestWeek is published by A.M. Best Co. for insuranceprofessionals.

BestWeek: Insurers, Regulators Left With Questions After Oral Arguments in PPACA Case. - Entertainment Close-up

Now that the U.S. Supreme Court has finished hearing oral arguments in the closely watched health care reform case, the industry is wondering how the high court's decision might affect the new status quo that has emerged since the law went into effect in 2010, according to the latest issue of BestWeek U.S./Canada.

The justices are expected to issue a ruling in U.S. Department of Health and Human Services v. Florida in June. Insurers, their brokers and regulators have many questions-particularly on the issue of how those with pre-existing conditions will be covered.

Through the Patient Protection and Affordable Care Act, Congress sought to address that problem by creating a mandate requiring all Americans to obtain health insurance or face a financial penalty. The thinking was if more healthy people were required to enter the risk pool, they would help to offset the increased risk associated with pre-existing condition consumers and to lower health insurance premiums. Three days of video coverage are included in the package.

In BestWeek Europe, European life insurers are being forced to adjust their business plans and capital management strategies in response to the eurozone credit crisis and regulatory changes including Solvency II, according to a new market review from A.M. Best Europe - Rating Service.

In a release, the group noted:

Also in BestWeek U.S./Canada, under fire for being too profitable and charging unreasonable rates, lender-placed insurance has been hit with a flurry of consumer complaints and several federal lawsuits.

Proponents say there would be no mortgages without an insurance safety net and rates higher than voluntary insurance reflect the broad risk that's insured without companies ever seeing the property, BestWeek said.

Gene Mergelmeyer, president and chief executive officer of Assurant Speciality Property, told BestWeek lender-placed insurance policies don't go through an underwriting process because they aren't individually written. He said his company contracts with lenders to insure all uninsured properties in the lender's portfolio.

'Literally on all the lapsed properties; without underwriting, without inspection, without knowing the property's condition or whether anyone is even living there,' Mergelmeyer said.

BestWeek: Insurers, Regulators Left With Questions After Oral Arguments in PPACA Case - Wireless News

Wireless News
04-07-2012
BestWeek: Insurers, Regulators Left With Questions After Oral Arguments in PPACA Case
Type: News

Now that the U.S. Supreme Court has finished hearing oral arguments in the closely watched health care reform case, the industry is wondering how the high court's decision might affect the new status quo that has emerged since the law went into effect in 2010, according to the latest issue of BestWeek U.S./Canada.

The justices are expected to issue a ruling in U.S. Department of Health and Human Services v. Florida in June. Insurers, their brokers and regulators have many questions-particularly on the issue of how those with pre-existing conditions will be covered.
Through the Patient Protection and Affordable Care Act, Congress sought to address that problem by creating a mandate requiring all Americans to obtain health insurance or face a financial penalty. The thinking was if more healthy people were required to enter the risk pool, they would help to offset the increased risk associated with pre-existing condition consumers and to lower health insurance premiums. Three days of video coverage are included in the package.

In BestWeek Europe, European life insurers are being forced to adjust their business plans and capital management strategies in response to the eurozone credit crisis and regulatory changes including Solvency II, according to a new market review from A.M. Best Europe - Rating Service.

In a release, the group noted:

Also in BestWeek U.S./Canada, under fire for being too profitable and charging unreasonable rates, lender-placed insurance has been hit with a flurry of consumer complaints and several federal lawsuits.

Proponents say there would be no mortgages without an insurance safety net and rates higher than voluntary insurance reflect the broad risk that's insured without companies ever seeing the property, BestWeek said.

Gene Mergelmeyer, president and chief executive officer of Assurant Speciality Property, told BestWeek lender-placed insurance policies don't go through an underwriting process because they aren't individually written. He said his company contracts with lenders to insure all uninsured properties in the lender's portfolio.

'Literally on all the lapsed properties; without underwriting, without inspection, without knowing the property's condition or whether anyone is even living there,' Mergelmeyer said.

((Comments on this story may be sent to newsdesk@closeupmedia.com))

Copyright 2012 Close-Up Media, Inc. All Rights Reserved.

Payers must combine resources to red flag fraudulent claims - Managed Healthcare Executive

Public/private databases could identify bad apples

HEALTHCARE FRAUD costs Americans between 3% and 10% of each dollar spent, which sounds like a rounding error until one realizes that $2.34 trillion in spent on healthcare annually. At the high end of the scale, that translates to $234 billion, equivalent to the economic impact of the oil, tourism, fishing and shipping industries on the Gulf of Mexico.

A white paper from The National Health Care Anti-Fraud Assn. (NHCAA), 'Combating Health Care Fraud in a Post-Reform World: Seven Guiding Principles for Policymakers,' outlines proposals the group believes will curb the problem. Of particular interest is the idea that anti-fraud information should be passed freely among private and public insurers and that health plans should have more leeway to bar providers suspected of fraud.

NHCAA's Special Investigation Resource and Intelligence System (SIRIS) database, where health plans can report fraudulent providers, has been underutilized because of a reluctance to input the data, says Barry Johnson, president of HealthCare Insight, which provides payment integrity solutions.

Carriers 'look information up, but they don't put information in,' says Johnson. 'I'm not aware of any sharing across health plans.'

Participating Blue Cross Blue Shield companies have collaborated on Blue Health Intelligence, which allows mining of claims data to uncover trends, including those regarding fraud and abuse.

T. Markus Funk, who leads the investigations and white collar defense group at Perkins Coie, believes the healthcare industry needs a common database, much like the informationsharing partnership between the Federal Bureau of Investigation and the private sector tracking cyberterrorism.

'Fraud schemes don't discriminate between public and private troughs of money,' says Funk, who prosecuted a number of healthcare fraud cases while serving as an assistant U.S. attorney. 'A highly fortified private/public partnership could help staunch the redistribution of wealth from law-abiding citizens to the criminal class.'

Funk acknowledges that private plans likely are reluctant to share information due to concerns about patient confidentiality and proprietary data, but he says those concerns are groundless.

Funk says. 'It's a false dichotomy to think you have to throw your books open,' he says.

The Patient Protection and Affordable Care Act (PPACA) calls for expansion of the CMS Integrated Data Repository that incorporates federal healthcare programs, but NHCAA suggests including private payer data so trends across both public and private plans can be identified.

'Deeper data results in more accurate analytics and an elimination of unnecessary inquiry,' says Willis Gee, vice president of claims integrity at Med Assurant. 'That is, all systems have some degree of 'false positive' rates. Greater access to data decreases this rate, allowing the legitimate provider to stand free and clear of any level of concern, while also allowing the system to pay more comprehensively once they know that fraud, waste and abuse have been eliminated from the system.'

Carrie Valiant, a partner at EpsteinBeckerGreen who specializes in healthcare fraud and abuse, appreciates the need to crack down on fraud. She's the co-author of 'Legal Issues in Healthcare Fraud and Abuse.'

'But there needs to be balance and established rules so good providers are not dissuaded from participating in various programs that are essential to the success of healthcare reform,' she says.

The possibility of disgruntled employees lodging specious complaints against a former employer is one concern. Another is how to determine whether shared data are reliable and what agency or authority will make those determinations. The fear of a provider being suspended without due process is another reason to be cautious, Valiant advises.

While the idea of expanding the federal database to include private payers has its appeal, Valiant says that government rules on eligibility and payment don't mirror those of private plans, which can create its own issues.

A shared database of non-proprietary information between public and private health plans would allow payers to weed out those who are abusing the system, another recommendation in the NHCAA whitepaper. However, policy guidelines from Medicare and many states require payers to accept any willing provider into their networks, with the belief that licensing boards will weed out the bad apples.

PPACA creates a screening process for providers that takes into account the potential risk of fraud, waste and abuse.

'I've had clients thrown out of the federal healthcare system because they forgot to file a piece of paper that they moved,' Valiant says. 'It used to be easy to get reinstated, but not any more.'

She notes that the enforcement climate has gotten more stringent, with overpayments now becoming civil fraud claims and what were once civil cases being pursued as criminal actions. The potential for overreach can chill the desire of providers to participate in certain insurance plans.

While there's always a possibility that providers might be removed because of a rudimentary mistake, 99% of healthcare fraud cases are just that ? fraud, says Funk.

'It's odd that the forms are filled out the same way and in a way that always benefits [the providers],' he says.

Gee says that data systems should encompass comprehensive case identification and validation. Insight from these processes can bring about changes in preauthorization, contracting and documentation requirements that can aid legitimate providers while thwarting those trying to game the system.

'I wholeheartedly agree with the Government Accountability Office's new mandate to shift from a payand-chase' mindset to 'preventionand-detection' for fighting long-term healthcare fraud,' says Jonathan Marks, partner-in-charge at Crowe Howarth LLP's fraud, ethics and anti-corruption services. 'A national database of questionable providers, for example, could be used to monitor swings in accounts payable and accounts receivable.'

Other fraud detection tactics he suggests include random audits and mandatory IT upgrades for practices with significant Medicare revenue, enhanced background checks on new hires and the creation of a national hotline audited annually. Mandatory coding certification administered by one national organization also could stem instances of fraud, Marks says.

PROVIDER NETWORK WINS OUT

In areas of the country where physician or hospital coverage is sparse, private payers sometimes look the other way when dealing with fraudulent claims, says Johnson.

'In certain instances where providers were clearly abusing the system, organizations weighed the cost of penalties [for gaps in coverage] versus losses due to fraud,' he says. 'We have to fix this somehow.'

Laws penalizing payers for failing to settle claims within a certain time window exacerbate the chance for fraud, as do low reimbursement rates for Medicare and Medicaid. But the status quo definitely is not working, Johnson says.

'If 95 out of 100 are playing by the rules, we can't let the other five get away with it,' he says.

[Sidebar]

MHE EXECUTIVE VIEW

* Sharing data on fraudulent providers can prevent losses.

* Balance protective measures with the needs of legitimate providers.

* Don't be reluctant to report possible fraud.

[Author Affiliation]

U.S. to Blues: Quid pro no; Hospitals pressured to deal, suit says. - Crain's Detroit Business

Byline: JAY GREENE

Blue Cross Blue Shield of Michigan's failed purchase of a Lansing-based health maintenance organization earlier this year led to the antitrust lawsuit filed last week by state Attorney General Mike Cox and the U.S. Department of Justice.

The lawsuit, filed Oct. 18 in U.S. District Court in Detroit, alleges the state's largest health insurer pressured 23 of the state's 131 hospitals to sign illegal 'most favored nation' contracts that required them to charge higher prices to competing health insurers. It asks for the clauses to be removed.

Joy Yearout, the attorney general's deputy director of communications, said the attorney general's office became aware of the clauses during its investigation of the proposed Blue Cross acquisition of Physicians Health Plan of Mid-Michigan. The Blue Cross and PHP deal, proposed in September 2009, fell apart in March after the federal government threatened to challenge it.

'Following that discovery earlier this year, our office issued subpoenas to other Michigan hospitals to examine their contracts with Blue Cross,' Yearout said.

In its investigation, the Justice Department and Cox's office found that in 2007 Blue Cross threatened to cut payments by up to 16 percent to 45 small and rural hospitals if they did not agree to the most-favored-nation contracts.

Blue Cross also allegedly required 23 larger hospitals to charge more than 20 percent more than Blue Cross rates. One hospital, Covenant Medical Center in Saginaw, was required to charge 39 percent more to other insurers.

In an interview with Crain's, Andy Hetzel, Blue Cross' vice president of corporate communications, said Blue Cross has used most-favored-nation clauses in its contracts since 2007 only to negotiate the lowest price it can to keep premiums low.

Hetzel denied that Blue Cross contracts require hospitals to charge competing insurers higher prices.

Greg Moore, health care practice leader with Clark Hill PLC in Birmingham, said he suspects one of Blue Cross' competitors could have provided prosecutors with information on the Blues' contracting practices during the investigation.

'It is curious to me why they are doing this now. My suspicion is there is a backstory here. Maybe a competitor is looking to get' an edge over Blue Cross, Moore said.

According to the lawsuit, Blue Cross wrote during negotiations in 2008 with a Grand Rapids hospital that 'we need to make sure they (the hospital) get a price increase from Priority if we are going to increase their rates.'

Hetzel acknowledged that in 2007 Blue Cross began each contract with a preamble that discussed most-favored-nation contract status. But he said the only requirement was that hospitals give Blue Cross best prices.

'Our contracts only relate to Blue Cross reimbursement rates,' Hetzel said. 'It doesn't relate to rates with other contracts with other insurers.'

However, Rick Murdock, executive director of the Michigan Association of Health Plans, said Blue Cross has 'side agreements' with most hospitals in the state in addition to a standard participating hospital agreement with the Michigan Health and Hospitals Association that also applies to all hospitals.

'Every (insurer) should negotiate the best deal they can, and more power to them if they get deep discounts,' Murdock said. 'But when you take advantage of your economic power and stifle competition, (then) that is going over the line.'

In one example cited in the lawsuit, Priority Health, which has an office in Farmington Hills, wanted to offer insurance in the Upper Peninsula and compete with Blue Cross.

However, because Marquette General Hospital had signed a most-favored-nation contract with Blue Cross, Priority Health concluded it could not compete in the U.P.

'Other commercial insurers, including Assurant and Health Alliance Plan, likely also would have entered into agreements with Marquette General if they had been able to contract (with the hospital) at prices Blue Cross pays to Marquette General,' said the lawsuit.

Another example describes a contract between Sparrow Hospital in Lansing and Blue Cross that allows existing contracts between Sparrow and other insurers to continue only until Jan. 1.

'After that date, Blue Cross' (most-favored-nation contract) will likely require Sparrow to raise prices to McLaren Health Plan,' said the lawsuit. 'The resulting higher costs will reduce McLaren's effectiveness as a competitor to Blue Cross.'

The Blue Cross contract with Sparrow 'also prevents Priority Health and HealthPlus of Michigan from entering the market in a manner that would create effective price competition to Blue Cross,' the lawsuit said.

Murdock said many health plans in Michigan feel they are unfairly paying double-digit higher rates to hospitals than the Blues does.

'It is too early to tell how the complaint will be resolved,' Murdock said. 'If you eliminate the barriers that this appears to bring, clearly you will have more carriers interested in doing business in the state.'

William Berensen, Aetna's Michigan market president, said competition in the health insurance market is crucial in providing value to consumers.

Earlier this year, Aetna decided it would pull out of Michigan's small-business group market next February because sales are lagging. That market represents a small percentage of Aetna's 300,000 customers in Michigan, he said.

Berensen said Aetna's decision remains unchanged with the news of the Blue Cross lawsuit.

'Any time payer, hospital or physician pricing is significantly out of line, it can create an uncompetitive market and consequently a burden to employers and consumers,' Berenson said. 'It should be the goal of everyone to ensure competitiveness.'

Officials for Humana, Priority Health, Health Alliance Plan of Michigan, and St. John Providence Health System declined to comment. A spokesman for William Beaumont Hospitals said executives are cooperating with the investigation.