Episode Details

I couldn't resist the "who's suing who" because, yeah, you can't go wrong with Aretha Franklin references.

Back on the pod we have Chris Deacon, who is going to give us a rundown of the legal goings-on going on right now that impact self-insured employers, carriers, hospitals, and taxing authorities like cities.

Chris breaks down the legal activity into three main categories, and then we discuss some examples of lawsuits in each category. So, here's the outline of our upcoming conversation:

1. Breach of Fiduciary Line of Cases Against Carriers

a. Bricklayers vs Anthem Class Action

b. Mass Laborers vs Blue Cross Blue Shield

c. Member vs Cigna

2. Carrier vs Hospital (upcoding) and Hospital vs Carrier (underpayment)

a. United vs TeamHealth

b. TeamHealth vs United

3. Taxing Authority vs Nonprofit Hospitals

a. Tower Health line of cases in Pennsylvania

b. Pittsburgh vs UPMC

This episode itself is a little on the longer side—and I didn't want to edit too many of Chris's words of wisdom—so I'm gonna make this a little bit shorter, this intro.

But just one point that I'll make, and this is about the first category of legal activity wherein self-insured employers mostly try to pass the "who is actually the fiduciary" hot potato to carriers, ASOs (administrative services only), and TPAs (third-party administrators). And the carriers, ASOs, and TPAs are like, "It ain't us." Moving forward here, I'm just gonna say carriers as a catchall for carriers, ASOs, and TPAs to save myself a mouthful.

But bottom line on this topic, I just want to underscore something that Chris makes clear later on in the show: Plan sponsors (ie, self-insured employers) are the fiduciary, the sole fiduciary, at least according to the carriers who are getting sued right now. This is the position that you can see them taking in every lawsuit that I have seen. What the carriers say also, as a follow-on, is that if there is any contractual language between the carrier and the employer that violates the CAA (Consolidated Appropriations Act) or any other regulations, it is or was the employer's responsibility to not sign the contract.

It's not the carrier's responsibility to point out that there's stuff in their own contract that's in violation for the employer to sign. And this includes contracts that don't give self-insured employers the right to their own data, which is pretty much a rate critical for any and all CAA compliance.

As Justin Leader wrote the other day in reference to the bricklayer case, "To get to the point of filing the suit, there was a solid 2 years of failed negotiations [for the bricklayers to get their own claims] data."

Two years trying to get claims data that is necessary for a fiduciary to have from a carrier who is saying essentially, "Good luck with that. You're the ones that signed our contract."

Here's one of Chris Deacon's latest

Listen Now