Viewing posts from: August 2017

Compliance Alert | Properly Distributing ERISA Health and Welfare Plan Materials

Posted August 21, 2017 by Megan DiMartino

For more information contact The information contained in this post, and any attachments, is not intended and should not be misconstrued as legal advice. You should contact your employment, benefits or ERISA attorney for legal direction.

2017 Drafts of Form 1094/1095 Information Returns

Posted August 18, 2017 by Megan DiMartino

The Internal Revenue Service (IRS) has issued the 2017 drafts of the Form 1094/1095 information returns for the 2017 tax year with filing in early 2018.

  • Forms 1094-B/1095-B – used by coverage providers to report health plan enrollment required by Code § 6055
  • Forms 1094-C/1095-C – used by applicable large employers (ALEs) to report information relevant to Code § 4980H employer shared responsibility penalties required by Code § 6056

ALEs that sponsor self-insured health plans are considered coverage providers and fulfill their Code § 6055 requirement by reporting coverage information on Form 1095-C. The forms also provide information regarding the shared responsibility penalty and premium tax credits.

The new 2017 forms also have a few differences from the 2016 forms:

  • Form 1094-B – which is the transmittal for Form 1095-B, is unchanged.
  • Form 1094-C – removed line 22 box for “Section 4980H Transition Relief.” This relief was only applicable for the 2015 plan year.
  • Forms 1095-B and 1095-C – had no major changes. Although, a new paragraph was added in the instructions for recipients titled “Additional information.” This refers recipients to an IRS webpage that provides an overview of the provisions of the individual shared responsibility, employer shared responsibility, and premium tax credits along with contact information for the IRS Healthcare Hotline for questions.

Per EBIA – Draft instructions should most likely be coming out soon which provide a more complete picture of reporting for the 2017 tax year. There has been no change to the reporting requirements as we’re still under the Affordable Care Act (ACA).

For more information contact The information contained in this post, and any attachments, is not intended and should not be misconstrued as legal advice. You should contact your employment, benefits or ERISA attorney for legal direction.

Your Network Discount Analyses Are Useless

Posted August 16, 2017 by Megan DiMartino

Throw it in the trash. Seriously. The time we spend as insurance professionals, benefits professionals, and HR professionals analyzing insurance network discount reports might as well be time spent playing “Candy Crush” on our phones. The similarities are striking actually; they both contain bright colors, you feel like you are exercising your brain, immediately upon finishing there’s a sense of understanding and achievement, and then 5 minutes later, you question, “why did I just spend 45 minutes doing that?”

Insurance carriers and networks have done a tremendous job in promoting the value of their provider networks. We painstakingly agonize over geo-access reports, and we love taking our claims and running them through the various carriers to see if we could save a couple of percentage points with UnitedHealthcare, Cigna, Aetna, or the Blues. And why not…a 2% discount savings for most of us ends up being over $200 per employee per year. That adds up.

So why should we throw those reports out?

The answer is simple…it doesn’t matter what your discounts are when the discount is not based off of anything.

Think of the mattress store in your town that has been “going out of business” for what seems like the past four years. All of the mattresses are 80% off! What a steal! It would be a great deal, except the mattress is 80% off of a marked up price that has no basis in reality. Who would pay a $12,000 sticker price for a basic queen sized, spring mattress?

Or think about when your spouse comes home with three new outfits. It was buy one, get two free! I got two free outfits! Again, it would be a great deal if the first outfit wasn’t four times more than you might be able to get it somewhere else. You didn’t get two outfits for free, you overpaid for three outfits.

In short, a discount only means something when the price that the discount is based off of can be referenced at other locations. I’d rather pay full price for an item at $100 than get a 50% discount on that same item where the sticker price is $400…wouldn’t you?

So how do we bring this full circle back into healthcare? Consider your claims for inflammatory conditions that are run through your medical plan. Most are known as HCPCs J-Codes. J1745 is a big one, for example…you probably have quite a bunch of claims for that…Infliximab…also known as Remicade. Carrier A has negotiated with their hospitals that they will discount Remicade 50% off of their billed charges (queen-sized mattress anyone?). Carrier A has negotiated with non-hospital providers that they will reimburse ASP +15% for the same exact drug. Now we compare Carrier A with Carrier B. Carrier B only has a 45% discount on billed charges for Remicade at the hospitals, and the same ASP +15% arrangement with the non-hospital providers. So when we re-run claims through both carriers, Carrier A looks like a champ and Carrier B is the chump, right?

But let’s now assume that Carrier B also has a program that redirects members from outpatient hospital setting for Infliximab infusions to the non-hospital provider settings. Let us also assume that they can quantitatively prove a 90% conversation rate from the hospital to non-hospital setting. Are they still the chump?

Consider this: your average PEPY spend on healthcare sits around $10,000. So a 2% network savings is that $200 PEPY we mentioned before. Now consider that your average Remicade infusion at a hospital will cost a plan $9,000 per month, whereas at an office setting, the average would be closer to $4,000 per month. So a shift in that site of service can save a plan $60,000 per user per year. In other words, within a population of 300 employees, a 2% network savings has the same value as just one member changing where they receive their Remicade infusions.

Imagine what happens when you factor in other medications such as Humira, Tecfidera, HP Acthar, Cinryze, Stelara, and dozens of others? Or imagine the impact of setting a reference based price for your imaging, or having negotiated bundled pricing for orthopedic surgeries? All of a sudden, those network discounts and access fees start to look less and less significant.

Now, let’s compare John and Jane who are both requiring a knee replacement. John goes to Hospital A and Jane goes to Hospital B. Both have negotiated a 50% discount of billed charges, but Hospital A bills $80,000, so the allowed charge is $40,000, while Hospital B bills $60,000, so the allowed charge is $30,000. Your discount report will show a 50% “discount” at both, but who cares? Meanwhile, Eric is covered under a different plan that has set a bundled reimbursement with the Hospital C at $25,000. Hospital C bills that $25,000, so the discount is 0%. Yet, we’d all prefer to take that 0% discount all day long.

It has been decades since the days of the Major Medical reasonable and customary reimbursement plans, but Medicare based reimbursements for non-Medicare members, as well as other UCR style programs, are starting to make a comeback, as is the growth in concierge medicine. What’s old is new again. It may not be long before insurance networks become completely irrelevant and obsolete in this new environment.

In the meantime, look at your claims and your data from the perspective of unit cost. Compare medical drug spend to the published Part B reimbursements on the CMS website. Compare different hospital billed and allowed charges for the same exact procedures within your own populations. Evaluate where people are going for infusions, surgeries, imaging, and lab work. Look at carriers and TPAs from the standpoint of who is going to manage the efficiency of utilization as opposed to which network will offer the “deepest” discounts.

If you shift your point of view, you might see a completely different picture.

Source: Crawford Advisors’ Director of Analytics, Scott Mayer | Your Network Discount Analyses Are Useless

For more information contact The information contained in this post, and any attachments, is not intended and should not be misconstrued as legal advice. You should contact your employment, benefits or ERISA attorney for legal direction.

HRCI & SHRM Pre-approved Crawford Advisors Webinar Series | Voluntary Benefits: Choosing the Right Fit

Posted August 15, 2017 by Megan DiMartino

Join Crawford Advisors’ Director of Voluntary Benefits, Stephen Ivey, for this HRCI* and SHRM** pre-approved, complimentary, one-hour webinar as he explores how to design, communicate and administer voluntary plans. Listen in on how these benefits are customized specifically to an employer’s core benefits program instead of the more common one-carrier-fits-all approach in the market.

Topics include:

  • Primary vs Supplemental
  • State of the Market
  • Employer Risks/Concerns
  • Communication & Enrollment Strategies
  • Administrative Platforms

Webinar Details:

  • Thursday, August 24, 2017
  • 1:00 – 2:00pm EDT
  • No Cost to Attend
  • This webinar is open to all HR and Finance Professionals – but not to brokers, agents, TPAs and PEOs.

*The use of this seal confirms that this activity has met HR Certification Institute’s (HRCI) criteria for recertification credit pre-approval. This activity has been approved for 1 HR (General) recertification credit hours toward aPHR, PHR, PHRca, SPHR, GPHR, PHRi, and SPHRi recertification through HRCI.

**Crawford Advisors is recognized by SHRM to offer Professional Development Credits (PDCs) for SHRM-CP or SHRM-SCP. This program is valid for 1 PDC for the SHRM-CP or SHRM-SCP. For more information about certification or recertification, please visit

For more information contact The information contained in this post, and any attachments, is not intended and should not be misconstrued as legal advice. You should contact your employment, benefits or ERISA attorney for legal direction.

We’re Hiring for Part-Time (Intern) Positions!

Posted August 2, 2017 by Megan DiMartino

Crawford Advisors is hiring for the following 4, part-time (intern) positions:

  • Marketing Assistant: The Marketing Assistant will support the underwriting team in preparing requests for proposals, following-up on carrier quotes, inputting data in various systems, reviewing proposals for accuracy, and other duties as assigned.
  • Account Management Assistant: The Account Management Assistant will support the account management team by reviewing carrier proposals for accuracy, inputting data in various systems, preparing open enrollment materials, and administrative/other duties as assigned.
  • Customer Service Assistant: The Customer Service Assistant will support the customer service representatives by entering client data into the system, processing employee changes and terminations, tracking carrier or client issues, and other duties as assigned.
  • FSA Assistant: The FSA Assistant will support the FSA representatives in their day-to-day responsibilities of customer service to FSA clients, claims processing, entering client data into the system, and other duties as assigned.

If you, or anyone  you know, are a good fit for any of the above positions, please send your resume to

Thank you so much for your interest and we can’t wait for you to join the Crawford Team!

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