The following case relates to a worker's compensation case where the member sustained serious neck and spine injuries and had retained an attorney to help him with this claim against the WC carrier. The member's attorney contacted us right away with a request of our lien and a reduction of the lien amount, stating that this would not be worth pursuing otherwise. We satisfied his request and advised we cannot reduce for medicals until we know what other lien holders there were and what the settlement would look like. We also sent along the plan's language which was very strong, calling for 100% reimbursement.

During negotiations, the member switched representation, retaining a new attorney. Starting from scratch, we again sent our lien and a list of related medicals, paid by the plan along with the plan language calling for 100%.  During the negotiation process, the group stipulated that they required full refund for medicals paid related to this injury. We relayed the plan's stance to the member's attorney and continued to work toward a resolution that would make everyone happy. Unsatisfied, the new attorney threatened to re-do the stipulation to hold the member harmless, essentially writing us out of the settlement document. Then we would have been forced to pursue the claim directly against the Workers Compensation carrier, as we would have had to prove that the claims on the list were indeed work related, among other issues. This would have cost more time, money & would not guarantee a reimbursement (causation issues). Instead, we explained the situation to the plan and received settlement approval to negotiate a fair deal with the member's attorney and settled the case for 85% of the original lien amount. - A win all around.

People want the power to make decisions about their own health care and their family's health care, without having the government involved in their decisions. The after-effects of the Supreme Court's decision to uphold the constitutionality of health care reform has presented a "gap" for those citizens whose state choose not to expand Medicaid. The strike down of the mandatory expansion of Medicaid has created a hole in health insurance coverage that could harm some of the nation's poorest citizens. The bill drafters made no provisions of the reform law to provide subsidies for anyone below the poverty line, because they assumed they would be covered by extended Medicaid. Now that expansion is not mandatory, this leaves poor adults, without children, and parents with incomes below the poverty line, but above Medicaid eligibility without many options. They are ineligible for Medicaid and for tax credit to buy private insurance, but can still be taxed because they do not have health insurance.  The upholding of the mandate may not be a total disadvantage because the taxes do not exist yet and some people are not covered under Medicaid anyway. Either way, the decision of having health care should be left to the person or provider of the household, not the government.

What does the reform mean for TPAs? TPAs are not as affected directly by the reform, as the specific employer benefit plans and are still in a good position for the future. In these times, where productivity is key, the checklist for TPAs should start with growth. TPAs should try to expand in size, finding new lines of business or contacts and educate people on how to be good, informed consumers of healthcare.