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.

Madigan backs suit against Advocate - Chicago Sun-Times

Illinois Attorney General Lisa Madigan threw her support behind alawsuit filed against Advocate Health Care over how it charges theuninsured.

She filed an amicus brief last week asking the Circuit Court ofCook County not to dismiss the complaint. The suit accuses Advocateof overcharging the uninsured and seeks to force Advocate to halt thepractice and stop pursuing collections against such patients.

People lacking insurance typically get charged higher prices forservices at hospitals here and across the country. While insurancecompanies and third-party payers such as Medicare and Medicaid usetheir clout to negotiate big discounts off the gross, or 'sticker,'price for such services, the uninsured lack such discounts and arecharged the sticker price. Hospitals have drawn criticism across thecountry because of the practice, and it has led to other lawsuits.

But Advocate and other hospitals have maintained that federalMedicare law governs how they bill the uninsured.

Madigan disputed that argument in her brief. She cited a letterfrom U.S. Health and Human Services Secretary Tommy G. Thompson,written to the American Hospital Association earlier this year, whichreferenced a letter from the Chicago-based association on the issue.

Thompson's letter said, 'Your letter suggests that HHS regulationsrequire hospitals to bill all patients using the same schedule ofcharges, and suggests that as a result, the uninsured are forced topay full price for their care. That suggestion is not correct, anddoes not accurately reflect my policy. ... Hospitals can providediscounts to uninsured and underinsured patients who cannot affordtheir hospital bills and to Medicare beneficiaries who cannot affordtheir Medicare cost-sharing obligations. Nothing in the Medicareprogram rules or regulations prohibit such discounts.'

The agency has maintained that this position represents no policychange, Madigan notes in the brief.

'Discriminatory pricing policies that make health care vastly moreexpensive for low-income uninsured residents of Illinois violates thestate's public policy of improving access to health care among lowincome residents,' Madigan said. '...The allegations raised inplaintiffs' complaint, if true, would violate Illinois publicpolicy.'

Advocate spokesman Edward C. Domansky maintained that federalrules still play a role in how the uninsured are billed.

'There are provisions that talk about proof of indigence andmaking applications for charity care,' he said. 'The federalregulations still basically serve as a starting point for allnegotiations, whether with the uninsured, the government or healthinsurers. The uniform charge structure is still the requirement.Discounts can be offered once proof of indigence is determined.'

He also contended that one of the key roadblocks to offeringdiscounts and charity care to the uninsured is lack of patientcooperation.

***

Data released by Assurant Health reveals strong interest in newhealth savings accounts.

The health insurance provider, which covers more than 1 millionpeople nationally, said that in the first five months since offeringHSAs, it has received more than 56,000 applications from interestedconsumers, and 43 percent of the people did not indicate any priorhealth insurance coverage, Assurant said.

Milwaukee-based Assurant shared the data at a briefing in Chicagolast month with the Illinois Chamber of Commerce, the Illinoischapter of the National Federation of Independent Business and U.S.House Speaker J. Dennis Hastert. He sponsored the HSA legislation.

The accounts debuted this year in the Medicare reform law. Theaccounts are funded with contributions from consumers and employers,and provide high-deductible health plans for individuals andfamilies. That includes plans with at least a $1,000 annualdeductible per individual or a $2,000 annual deductible per family.The advantages of the plans are that individuals or their employerscan fund the accounts with pre-tax dollars and accumulate nontaxableearnings. Unused funds can be rolled over every year, and the moneyused to pay for medical expenses, also tax-free.

Additionally, by putting much of the responsibility for buyinghealth care in the hands of HSA owners, the thinking is thatconsumers will be more likely to shop for lower-priced care.

***

Lake Forest-based TAP Pharmaceutical Products Inc. won approvalfrom U.S. regulators last week to market its Prevacid drug for use bychildren ages 12 to 17 for two conditions.

ATTORNEY GENERAL BLUMENTHAL SAYS COURT RULING CONFIRMS SUSPICIONS OF ABUSIVE, PERVASIVE INSURANCE COVERAGE DENIALS - US Fed News Service, Including US State News

The Connecticut Attorney General issued the following news release:

Attorney General Richard Blumenthal today announced that a South Carolina court ruling this week alarmingly substantiates concerns here about Assurant Health Insurance's potentially abusive insurance coverage denials in cases of catastrophic illness.

Blumenthal said the state Department of Insurance (DOI) must act now to complete its long delayed audit involving Assurant's coverage denial practices so that his office can take immediate action to protect patients here.

The DOI claimed it would release an audit last month - but has failed to do so - involving Assurant Health Insurance's (a.k.a. Fortis and John Alden Company) retroactive or 'look-back procedures used to bar coverage on the basis that patients conditions pre-existed policy onset dates.

In the case of Mitchell v. Fortis Insurance Company, a South Carolina court found that Fortis pre-programmed its computer to recognize billing codes for expensive health conditions, triggering an automatic fraud investigation. The court awarded $15 million to the plaintiff, who was improperly denied coverage by Fortis for his AIDS treatment.

'This case confirms our worst suspicions - that Assurant calculatingly denies coverage for catastrophic illnesses,' Blumenthal said. 'Assurant promised benefits, but abandons them when they face cancer and other devastating diseases. Our Insurance Department must act now to issue the audit that it promised six months ago. This audit is vital to take legal action protecting Connecticut consumers denied vital promised health benefits.

'I am deeply disturbed by several reports of consumers - people suffering from debilitating diseases - who were questionably denied coverage. I have tirelessly urged our legislature to strengthen the law protecting patients from abusive and arbitrary denial of promised health benefits. In the meantime, my office is prepared to take any action necessary to enforce the law.'

Blumenthal said the highly focused audit - which he requested six months ago - could have been done quickly because only limited information about the company's short-term policies is needed for the review.

The audit is vital for Blumenthal's office to take legal action to stop potentially illegal or improper denial of health benefits. Several patients have complained after Assurant questionably denied coverage for life-saving treatments promised under short-term health plans.

Blumenthal said the audit should inventory all of Assurant's denials under its short-term policies on the basis of findings of pre-existing conditions. Those denials should then be cross checked with a categorical claims review of the particular conditions that were determined to be pre-existing.

The audit would allow state investigators to confirm whether Assurant provides meaningful coverage for diseases such as cancer with any level of consistency under its short-term health insurance policies.

Complaints to Blumenthal's office - and now the South Carolina decision -indicate a pattern of arbitrary or abusive coverage denial:

A 34-year-old woman was diagnosed with Hodgkin's Lymphoma one month after her enrollment in a six-month policy underwritten by Fortis Health Insurance. During a post-enrollment diagnostic visit, the woman recalled experiencing mild shortness of breath while exercising some six months prior to her doctor's visit. Fortis, in seeking to deny coverage, concluded that the shortness of breath she recalled during a single workout six months prior to enrollment constituted a pre-existing condition because the symptom should have caused her to seek medical treatment prior to enrollment.

ATTORNEY GENERAL BLUMENTHAL CLAIMS INSURER IMPROPERLY DENYING COVERAGE - US Fed News Service, Including US State News

The Connecticut Attorney General issued the following news release:

Attorney General Richard Blumenthal said his office has received several reports of insurance companies denying coverage based on questionable conclusions that patients' medical conditions pre-existed their insurance policies.

Blumenthal urged that the Department of Insurance (DOI) finalize and release an audit that he requested Acting Commissioner Susan Cogswell to launch more than four months ago.

The audit, which is vital for Blumenthal and the General Assembly to take enforcement and legislative action to stop potentially illegal or improper denial of vital health insurance coverage, has yet to be released.

Complaints to Blumenthal's office involve Assurant Health Insurance's (a.k.a. Fortis and John Alden Company) retroactive or 'look-back' procedures used to bar coverage on the basis that patients' conditions pre-existed policy onset dates.

'Compromising coverage of catastrophic illnesses is unconscionable and unacceptable,' Blumenthal said. 'The Insurance Department cannot delay this audit any longer - now more than four months old. Its results are vital to coverage for life-saving medical treatment.

'Improper use of so called preexisting conditions should be barred and banished. My office will continue to fight for stronger legislative protections against these practices.'

Blumenthal described two of more than a dozen cases under review by his Health Care Advocacy Unit:

* A 34-year-old woman was diagnosed with Hodgkin's Lymphoma one month after her enrollment in a six-month policy underwritten by Fortis Health Insurance. During a post-enrollment diagnostic visit, the woman recalled experiencing mild shortness of breath while exercising some six months prior to her doctor's visit. Fortis, in seeking to deny coverage, concluded that the shortness of breath she recalled during a single workout six months prior to enrollment constituted a pre-existing condition because the symptom should have caused her to seek medical treatment prior to enrollment.

Health insurer taken to task for improperly handling medical claims. - The Day (New London, CT)

Byline: Patricia Daddona

Mar. 30--Customers of an insurance company that denied claims by blaming pre-existing health conditions will get restitution, the state's insurance commissioner announced Thursday.

Commissioner Susan Cogswell also said Thursday that her department will continue investigating Assurant Inc.'s practices, which she said might be 'just the tip of the iceberg' for the company's customers.

The firm, based in Milwaukee, issues health insurance policies through subsidiaries Time (formerly Fortis), Union Security and John Alden Life insurance companies.

'We just did a small sampling of policies, and based on that we believe there are other policy holders that have claims that have been unjustly denied,' said Cogswell.

A health problem that existed before the patient obtained an insurance policy -- a pre-existing condition -- can mean that the new policy might not cover costs of treating the condition.

According to Mark Franklin, director of the department's consumer services' division, the department closely reviewed 547 of the companies' 1,279 cases. It then randomly selected 39 cases representing $220,000 in reversed claim denials and more than $57,000 in interest.

Franklin found that most of the claims he reviewed involved language about pre-existing conditions 'that were incorrectly applied or delayed.' In some cases, a company would tell the policyholder it was denying a claim it had not yet investigated, he stated in a department memo.

Some catastrophic illnesses resulted in recovered claims totaling tens of thousands of dollars, and one totaled $93,049, plus $29,323 in interest.

In one case, a patient's claim was denied four years ago based on an incorrect conclusion that a pre-existing condition prevented coverage, Franklin states. The reversed decision resulted in a payout of $1,122 and $42.17 in interest.

In another case, a policyholder was denied a claim for treatment for chondromalacia, also known as water on the knee, and joint pain in the lower leg. Three months later, the firm admitted that medical records about whether the condition was pre-existing were unclear. It paid out more than $5,000, plus $63 in interest.

Cogswell's settlement requires the insurance companies to:

--Repay policy holders, with interest, who had claims wrongfully denied based on an alleged pre-existing condition;

--Submit to a compliance audit for 2001 through 2007;

--Use more medical personnel in reviews of claims early and clarify record-keeping

--Educate customers about how to appeal denials.

As part of the agreement, the company admits no wrongdoing, and the department reserves the right to pursue other issues.

Attorney General Richard Blumenthal, whose office also received complaints, said the insurance department should have produced an audit and imposed penalties on the company.

'Assurant added insult to illness, compounding consumers' struggles with grave illnesses, cancer and other devastating diseases, with fears of losing their homes and possessions to pay for life-saving treatment that Assurant promised, but failed to pay,' he stated.

However, Cogswell said, 'it would be premature to determine the fine until we know how serious the problem is. My primary aim is to make sure that the policyholders that have unjustly denied claims get restitution with interest.'

Assurant spokesman Rob Guilbert said the company serves 1.3 million people in 43 states and last year paid more than $1.3 billion in claims nationwide. The firm 'agrees with' the insurance department's stipulations and regularly cooperates in market conduct reviews, he said. The firm has been in business since 1892.

'We're glad to be working with them on this,' Guilbert said. 'We've signed this agreement and we do work very hard to make sure our claims process is fair and equitable and consistent with state laws and industry standards. And we're always striving to improve that process.'

To see more of The Day, or to subscribe to the newspaper, go to http://www.theday.com.

Copyright (c) 2007, The Day, New London, Conn.

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