State regulators continue to expand their investigation of the claims

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ADVERTISEMENT/ADVERTISING MATERIAL 2011 VOLUME 1 THIRD PARTY ADMINISTRATOR UPDATE POLSINELLI.

Registration Change in Wyoming Compliance and Regulatory Services For additional information about our Third Party Administrator Compliance & Regulatory Services or the contents of this Update,

State Regulators Escheat Probe Expands State regulators continue to expand their investigation of the claims settlement practices of the life insurance industry.

Annuities Claim Settlement Practices Including Unclaimed Property ) to help coordinate regulatory investigations involving the claim settlement practices of life insurance companies.

1 ADVERTISEMENT/ADVERTISING MATERIAL 2011 VOLUME 1 THIRD PARTY ADMINISTRATOR UPDATE POLSINELLI.COM INSIDE THIS ISSUE State Regulators Escheat Probe Expands New Third Party Administrator Registration Requirement in Massachusetts Utah Enacts Law Prohibiting Rebates Client Spotlight Registration Change in Wyoming Compliance and Regulatory Services For additional information about our Third Party Administrator Compliance & Regulatory Services or the contents of this Update, please contact Steve Imber or Justin Liby. State Regulators Escheat Probe Expands State regulators continue to expand their investigation of the claims settlement practices of the life insurance industry. Working through the National Association of Insurance Commissioners (NAIC), state insurance regulators have formed a special task force ( Multistate Examinations/ Settlements Covering Life and Annuities Claim Settlement Practices Including Unclaimed Property ) to help coordinate regulatory investigations involving the claim settlement practices of life insurance companies. State insurance regulators have been investigating a number of large life insurance companies regarding their possible failure to pay death benefits to beneficiaries of life insurance policies. The alleged unfair practices include the use of the U.S. Social Security Administration s Death Master File by insurers for purposes of terminating payments under annuity contracts, but failing to use this same information to facilitate the payment of claims on life insurance policies. The task force is chaired by the Florida Office of Insurance Regulation, and the following states are participating in the task force: California, Illinois, Iowa, Louisiana, New Hampshire, New Jersey, North Dakota, Pennsylvania and West Virginia. In addition to the NAIC task force, the California Insurance Department and the Florida Office of Insurance Regulation have also conducted separate public hearings in this matter. Further, the California Insurance Department announced market conduct examinations of 10 large life insurance companies for their alleged failure to pay life insurance benefits. Among the possible violations of law discussed by California insurance regulators at their public hearing were: - Unfair claim settlement consistency practices - Failure to escheat - Failure to adequately control and monitor retained asset accounts Steve Imber (913) simber@polsinelli.com Justin Liby (913) jliby@polsinelli.com Additionally, there are also approximately 35 states that have hired Verus Financial LLC, a Connecticut firm which is attempting to find unclaimed assets for states. New York Attorney General Eric Schneiderman recently issued subpoenas to at least nine life insurance companies to assess consumer Chicago Dallas Denver Edwardsville Jefferson City Kansas City Los Angeles New York Overland Park Phoenix Springfield St. Joseph St. Louis Topeka Washington, D.C. Wilmington, DE

2 protection issues and to confirm whether these insurers have issued payouts on policies of deceased customers. Several class action plaintiff firms are also busy trolling for life insurance policy beneficiaries and investigating large life insurers for potential violations of state consumer protection and insurance laws. New York insurance regulators ordered life insurers to use the Social Security Death Master File to locate insureds and report on the effectiveness of their search for beneficiaries. The New York Insurance Department sent a 308 Letter to all 172 life insurers licensed in New York. Life insurers must attempt to determine if benefit payments are due, locate and make payments to beneficiaries, and submit a report on their results by September 30, The New York Insurance Department is also planning to develop an amendment to its unfair claims practices regulations to require life insurers to perform regular Death Master File checks and will also require insurers to collect more data in order to better track policyholders and beneficiaries. New Third Party Administrator Registration Requirement in Massachusetts The Massachusetts Division of Insurance (MA DOI) has implemented a new (TPA) insurance regulation that became effective May 27, The law requires third party administrators that administer health insurance business on behalf of Massachusetts residents to become registered with the MA DOI. The regulation does not grandfather in TPA s that were doing business in Massachusetts prior to May 27, TPA s subject to the new Massachusetts registration requirements are defined as: A person who, on behalf of a Health Insurer or purchaser of health benefits, receives or collects charges, contributions or premiums for, or adjusts or settles claims on or for residents of the Commonwealth. Third party administrator shall also include pharmacy benefit managers and any other entity with claims data, eligibility data, provider files and other information relating to health care provided to residents of the Commonwealth and health care provided by health care providers in the Commonwealth. A health insurer is defined to include insurance companies and any other entities providing coverage for health, dental or vision services. Applications for initial registration must contain the following: (1) A narrative description of its activities (2) A copy of the basic organizational documents of the TPA (3) Bylaws or similar documents regulating the internal affairs of the TPA (4) A listing of the services that the TPA offers (5) Proof that the TPA has contracts with insurance producers licensed in Massachusetts if the TPA will be managing the solicitation of new or renewal business on behalf of a health insurer TPA s must also report to the MA DOI any material changes to their initial registration within 30 days of such changes. TPA s must renew their registration annually no later than April 1 of each year and must also submit an annual report to the MA DOI no later than April 1 of each year, certified by at least two officers of the TPA. The annual report shall include information with respect to the TPA s self insured customers and other financial data. Failure to file the annual report in a timely manner will subject the TPA to a late penalty of not more than $100 per day. Any TPA which collects premiums for or adjusts claims for residents of Massachusetts on behalf of a health insurer that itself is required to submit an Annual Comprehensive Financial Statement to the MA DOI is exempt from the annual reporting requirements for those services that the TPA provides on behalf of the health insurer. POLSINELLI.COM PAGE 2

3 The MA DOI may, after a hearing, suspend or revoke the registration of any TPA if it finds: (1) The TPA failed to submit to the MA DOI the annual report (2) The TPA has its license or registration to do business suspended or revoked by any state (3) The TPA is insolvent or impaired (4) A proceeding for receivership, conservatorship, rehabilitation or other delinquency proceeding regarding the TPA has been commenced in any state (5) The financial condition or business practices of the TPA pose an imminent threat to the public health, safety, or welfare of Massachusetts residents The MA DOI may also impose a fine of not more $1,000 for each and every violation. If you have questions regarding the new registration requirement for third party administrators in Massachusetts, please contact Steve Imber at (913) or simber@ polsinelli.com; or Justin Liby at (913) or jliby@ polsinelli.com. Utah Enacts Law Prohibiting Rebates Utah recently enacted a new law addressing unfair inducements related to insurance. Utah House Bill 333, which became effective March 18, 2011, provides that a licensee, or an officer or employee of the licensee, may not induce a person to enter into, continue, or terminate an insurance contract by offering a benefit that is not specified in the contract or directly related to the contract. The new Utah law places additional limitations on both insurers and third party administrators. The new Utah law defines prohibited inducements to include providing a premium or commission rebate or paying the salary of an employee of a person who purchases an insurance product. The new law also places additional limitations on insurers and third party administrators, prohibiting them from engaging in the following services unless a fee is paid: Performing background checks on prospective employees Providing legal services Performing drug testing that is directly related to an insurance product purchased from the licensee Preparing employer or employee handbooks, except a licensee may: - Provide information for a medical benefit section of an employee handbook - Provide information for the section of an employee handbook directly related to an employment practices liability insurance product purchased from the licensee - Prepare or print an employee benefit enrollment guide Providing job descriptions, postings, and applications for a person that purchases an employment practices liability insurance product from the licensee Providing payroll services Providing performance reviews or performance review training Providing union advice Providing accounting services Providing data analysis information technology programs, although it is permissible to provide certain technology services such as electronic enrollment platforms or enrollment systems Providing administration of health reimbursement accounts or health savings accounts A de minimis gift or meal not to exceed $25 for each individual receiving the gift or meal is presumed to be a social courtesy that is not conditioned upon the purchase of insurance. If you have questions regarding permissible activities by third party administrators under the new law, please contact Steve Imber at (913) or simber@polsinelli.com. POLSINELLI.COM PAGE 3

4 Client Spotlight This section of our Update highlights our third party administrator clients, and we will continue to feature our third party administrator clients in future newsletters. In this issue, we focus on PROPS a service offered by Linkia, LLC. Professional Review of Orthotic & Prosthetic Services ( PROPS ), was created by Linkia, LLC ( Linkia ) to assist payers in administrative and clinical review of highdollar orthotic and prosthetic ( O & P ) claims. Claims for artificial limbs can contain as many as 50 different codes and cost $10,000 to $100,000. Medical managers assigned to review these claims are not accustomed to reviewing such intricate claims in such a specialized area. Linkia has found that almost 50% of these claims over $5,000 contain coding and clinical errors, generating potential savings to their customers over $4,000 per claim on average. Polsinelli Shughart is extremely proud of its association with Linkia. If you are interested in receiving more information on PROPS and/or Linkia, please contact Sarah Weiss at (301) or sweiss@hanger.com. Registration Change in Wyoming Wyoming has implemented a change in the TPA registration and renewal process to be effective March 31, TPA s transacting business in Wyoming on or before April 21, 2011 were notified of this change directly. Prior to this change, insurers were required to register and renew registrations for all TPA s with whom they did business. In 2012, the TPA s will be required to complete the registration and renewal requirements. Linkia, LLC is a specialty healthcare company dedicated solely to Orthotic & Prosthetic management and care. Linkia was founded by and operates as a subsidiary of Hanger Orthopedic Group, the nation s largest provider of O & P services. All of the nation s largest health plans contract with Linkia for O & P services. Linkia s extensive knowledge and experience in the O & P industry has enabled health plans to improve their O & P service delivery to their insureds, while helping to reduce their administrative expenses. The registration and renewal registration will include the provision of an annual financial statement listing the insurers represented and the amount of funds handled for each insurer. At renewal in March 2012, each TPA will need to post one bond in an amount based upon the total funds handled by the TPA. TPA s that enter into a contract with a new insurer during any year must submit to the Wyoming Department of Insurance an Insurer Appointment of Third Party Administrator for the new insurer being represented. Linkia is licensed as a third party administrator and utilization review organization in many states and is URAC accredited. POLSINELLI.COM PAGE 4

Compliance and Regulatory Services Polsinelli Shughart is pleased to offer its Third Party Administrator Compliance and Regulatory Services to TPAs and insurers.

license or register TPAs. Assist TPAs and insurers with on-site audits and operational reviews. Assist TPAs responding to regulatory investigations or regulatory actions.

5 Compliance and Regulatory Services Polsinelli Shughart is pleased to offer its Third Party Administrator Compliance and Regulatory Services to TPAs and insurers. Services provided to TPAs and insurers include, but are not limited to: TPA licensing and registration with state insurance departments on a multi-state or national basis in the 42 states that license or register TPAs. Assist TPAs and insurers with on-site audits and operational reviews. Assist TPAs responding to regulatory investigations or regulatory actions. Assist TPAs with annual license/registration renewals and reports. Review of Administrative Service Agreements for compliance with state laws. Assistance with Market Conduct Examinations. Assist TPAs with foreign qualifications with Secretaries of State. Polsinelli Shughart s Insurance Business and Regulatory Law group has experience representing third party administrators and other insurance businesses on a variety of compliance and regulatory issues on both a state and national basis. Attorneys in our group include a former state director of insurance, two members who were formerly general counsel at state insurance departments, as well as three members who were formerly in-house counsel for third party administrators. SPECIAL THANKS to Polsinelli Shughart attorneys Jennifer L. Osborn and Keith A. Wenzel for their contributions to this newsletter. Jennifer L. Osborn Keith A. Wenzel The Update is a source of general information concerning third party administrators. Polsinelli Shughart provides this material for informational purposes only,. The material provided herein is general and is not intended to be legal advice. Nothing herein should be relied upon or used without consulting a lawyer to consider your specific circumstances, possible changes to applicable laws, rules and regulations and other legal issues. Receipt of this material does not establish an attorney-client relationship. Polsinelli Shughart is very proud of the results we obtain for our clients, but you should know that past results do not guarantee future results; that every case is different and must be judged on its own merits; and that the choice of a lawyer is an important decision and should not be based solely upon advertisements. Copyright 2011, Polsinelli Shughart PC. In California, Polsinelli Shughart LLP. POLSINELLI.COM PAGE 5

TPA Agreement Filing and Compliance Requirements

TPA Agreement Filing and Compliance Requirements Inside his Issue 1 2 4 5 PA Agreement Filing and Compliance Requirements Regulatory Actions Against Unlicensed PAs Proposed New Jersey Assembly Bill 427 Louisiana Insurance Department Directive 208 California