First Facilities Fined for Non-compliance with Hospital Transparency Rule

The Centers for Medicare and Medicaid Services (CMS) has issued fines to two hospitals in the Northside health system in Atlanta for not following the hospital transparency rule. Northside Hospital Atlanta, and Northside Hospital Cherokee were fined a combined $1.1 million dollars for failing to release machine-readable files of the standard charges for all items at the hospital including supplies and room and board.

The hospital transparency rule took effect in January 2021, however, only 6% of hospitals are fully complying with the federal law. Until this fine, no hospitals or health systems had received a fine for not complying with the transparency rule. Both hospitals were under corrective action plans (CAP), from December and January, and neither had fulfilled the requirements, leading to the fines. We will likely see more fines imposed as CMS follows up with hospitals with corrective action plans. 

Source: Healthcare Finance News 

TPA’s Quick Denial of Workers’ Comp Claims Draws Penalty 

The W.R. Berkley Corp, (BerkleyNet) a third-party administrator group, denied claims for workers’ compensation cases without “conducting a reasonable investigation” or “engaging in a good-faith attempt at a settlement”. The claims were for PTSD and other occupational diseases for first responders. 

The Vermont Department of Labor ruled in 1996 that mental disorders are eligible for compensation. The ruling strengthened in 2017 when the legislature passed a law creating a “presumption that any PTSD suffered by police officers, rescue or ambulance workers and firefighters is compensable unless a preponderance of the evidence shows the disorder was caused by risk factors not related to work.” 

BerkleyNet was required to pay an $85,000 administrative penalty and ordered to pay $15,000 to the victim restitution fund which is used to support first responders.   

Source: InsuranceJournal.com 

Texas to Penalize TPAs Who Assist Unauthorized Insurance Businesses 

The Texas Department of Insurance is warning TPAs to make sure they are not working with unauthorized insurance providers, or they risk penalties of up to $10,000 for each violation and suspension of the agent or TPAs license.

Some of the actions that could bring penalties to a TPA include: 

• Taking or receiving an application for an unauthorized insurance product 
• Receiving or collecting any consideration for the product including premiums, commissions, membership fees, assessments, etc. 
• Issuing or delivering a contract for the product 
• Directly or indirectly acting as an agent for or otherwise representing or assisting in: 
• Soliciting, negotiating, procuring, or effectuating the product or renewal of the product 
• Sending information about the product’s coverage or rates 
• Forwarding an application for the product 
• And more. Read all the actions here. 

Source: InsuranceJournal.com 

ACA’s “Family Glitch” Makes Healthcare Unaffordable 

While the Affordable Care Act (ACA) was created to help provide more access to healthcare for Americans, a glitch in the system prevents an estimated 5.1 million people from accessing affordable healthcare. This glitch doesn’t allow workers with families to qualify for affordable plans in the ACA marketplace, even if their employer doesn’t provide an affordable alternative.

The ACA rules state that if an employer offers an affordable self-only coverage plan, the employee (and their dependents) won’t qualify for ACA coverage. Unfortunately, when an employee has a family and needs coverage for dependents, the plans often jump considerably in price and can be unaffordable. This then leaves the family with no affordable options for health care. 

The IRS proposed a revision of this rule on April 5, 2022, and the revision could go into effect as early as January 1. 2023. However, it could also be delayed. In the meantime, employers should help employees navigate the ACA, otherwise, they may lose more staff.  

Source: BenefitNews.com 

A Delay in Determining Benefits Opens Door for a Man to Sue for Long-term Disability Benefits Under ERISA 

A man who was attempting to sue The Hartford Life and Insurance Company for violating ERISA rules was allowed to proceed with his lawsuit because Hartford did not provide a final decision on his benefits within 45 days of his administrative appeal as required by ERISA.

ERISA provides access to federal courts for claimants who need replacement income from disability benefits. Because Hartford did not make a claim determination in the 45 days nor ask for extended review time, the Second Circuit of the U.S. Court of Appeals ruled that a “non-final decision” was, in fact, a benefit determination. 

Source: BenefitsPro.com