Category: Daily News

There is rapid demand for insurance third party administrator (TPA) for handling the claims of worker’s compensation offered by employment firms under employee benefits. In addition, TPAs are used to manage company’s group benefits, particularly health, workers compensation, and dental claims that are typically self-funded.

A new study published by Allied Market Research reports that the insurance third party administrator market size was valued at $280.69 billion in 2020, and is projected to reach $514.98 billion by 2030, growing at a CAGR of 6.3% from 2021 to 2030.

Rapid adoption of third party administrators in the health insurance industry and rise in need for operational efficiency & transparency in insurance business process are some of the factors propelling the insurance third party administrator market growth. However, security issues and privacy concerns are the major factors limiting the market growth.

On the contrary, technological advancements in third party administrator, such as adoption of Internet of things (IoT), artificial intelligence, machine learning, and robotics process automation, have led to the growth of the insurance third party administrator industry.

Furthermore, artificial intelligence technology has claims administration with predictive outcomes, wherein a low-cost claim can be identified automatically through processing & eliminating the need for claim adjustment intervention. Thus, the demand for insurance third party administrator market is expected to grow tremendously in the coming years.

The insurance third party administrator market is fragmented with the presence of regional vendors such as CRAWFORD & COMPANY, SEDGWICK, and Charles Taylor. North America dominated the insurance third party administrator market, in terms of revenue in 2020, and is expected to retain their dominance during the forecast period. However, Asia-Pacific is anticipated to experience significant growth in the future as insurance TPAs play an important role in terms of enhancing customer relationships and delivering niche & unique insurance third party administrator services in this region.

The report analyzes the profiles of key players operating in the insurance third party administrator market such as Charles Taylor, CORVEL, CRAWFORD & COMPANY, ESIS, ExlService Holdings, Inc., GALLAGHER BASSETT SERVICES, INC., Helmsman Management Services LLC, Meritain Health, SEDGWICK, and United HealthCare Services, Inc. These players have adopted various strategies to increase their market penetration and strengthen their position in the insurance third party administrator market.

The outbreak of COVID-19 is anticipated to provide growth opportunities for the Insurance third party administrator market expansion during the forecast period, owing to rise in digital transformation trend in insurance and surge in demand for third party administration solutions that are hosted or managed on the cloud.

Moreover, during the pandemic, there is a rising number of claims in health insurance. Therefore, to effectively handle such high number of claims, the insurance companies are heavily investing in third party administrator services. Thus, these factors ensure that insurance companies are considering third party administrators for improving cost efficiency and business operations during the pandemic situation.

The California Insurance Fraud Protection Act (IFPA) allows qui tam plaintiffs to file lawsuits on the government’s behalf and seek monetary penalties against perpetrators of insurance fraud. Under the IFPA, a defrauder is assessed penalties for each fraudulent insurance claim it presented to insurers. To prevent duplicative lawsuits, the IFPA contains a “first-to-file rule” that bars parties from filing subsequent actions related to an already pending lawsuit.

State Farm Mutual Automobile Insurance Company filed an IFPA action alleging defendants Sonny Rubin, M.D., Sonny Rubin, M.D., Inc., and Newport Institute of Minimally Invasive Surgery fraudulently billed insurers for various services performed in connection with epidural steroid injections.

However, a month prior Allstate filed a separate IFPA lawsuit against the same defendants, alleging they were perpetrating a fraud on Allstate, also involving epidural steroid injections.

In the State Farm lawsuit, the trial court sustained defendants’ demurrer to State Farm’s complaint under the IFPA’s first-to-file rule, finding it alleges the same fraud as Allstate’s complaint

State Farm appealed, arguing its complaint alleges a distinct fraud. The Court of Appeal agreed that the demurrer was incorrectly sustained, but for another reason in the published case of P. ex rel. State Farm Mutual Automobile Ins. Co. v. Rubin 12/14/21 CA4/3.

In applying the rule, the trial court and both parties only focused on whether the two complaints allege the same fraudulent scheme. But, in this matter of first impression, the Court of Appeal finds the IFPA’s first-to-file rule requires an additional inquiry.

Courts must also review the specific insurer-victims underlying each complaint’s request for penalties. If each complaint seeks penalties for false insurance claims relating to different groups of insurer-victims, the first-to-file rule does not apply.

A subsequent complaint is only barred under the first-to-file rule if the prior complaint alleges the same fraud and seeks penalties arising from the false claims, submitted to the same insurer-victims.

Here, both complaints largely seek penalties relating to separate pools of victims. Allstate’s complaint only seeks IFPA penalties for the false insurance claims that defendants presented to Allstate. State Farm’s broader action seeks penalties for all the false insurance claims that defendants submitted to any insurer. Allstate is the only overlapping victim.

Thus, even if the two complaints allege the same fraud, State Farm is only precluded from pursuing IFPA penalties for the false claims that defendants billed to Allstate. As to the other inquiry, there is partial overlap between the fraudulent schemes alleged in the complaints.

Both complaints allege a common scheme in which defendants presented false claims to insurers pertaining to epidural steroid injections. However, State Farm’s complaint also alleges a distinct scheme involving false charges for magnetic resonance imaging (MRI) interpretations that defendants billed independently from epidural spinal injections.

For the portion of State Farm’s action based on MRI charges billed independently from epidural spinal injections, State Farm may pursue penalties for any false claims that defendants submitted to any insurer, including Allstate.

In an announcement on Wednesday, the U.S. Supreme court said that on January 7, it would hear oral arguments on separate disputes challenging the Biden administration’s mandate for businesses with more than 100 employees, and for some 17 million health care workers at facilities receiving Medicaid and Medicare funding.

The court, which has a 6-3 conservative-leaning majority, delayed action on emergency requests in both cases that sought an immediate decision. The workplace mandate is currently in effect nationwide, while the health care worker mandate is blocked in half of the 50 U.S. states.

The mandate for health care workers was issued last month by the Centers for Medicare and Medicaid Services (CMS), and affects roughly 17 million workers. It requires facilities that receive Medicare or Medicaid funding to require workers to get vaccinated, and has no testing opt-out.

The deadline for meeting the mandate is Jan. 4, 2022. However, OSHA said on Dec. 18 that it would not be issuing fines to businesses for noncompliance until Jan. 10.

The Biden administration’s private employer COVID-19 vaccine mandate, meanwhile, was promulgated by the Department of Labor’s Occupational Safety and Health Administration (OSHA). If allowed to take effect next month, it will force every business with 100 or more employees to require proof of a negative COVID-19 test on at least a weekly basis or proof of vaccination from each worker. Companies that don’t comply would face escalating fines.

The White House on Wednesday said that it is “confident in the legal authority for both policies.”

The announcement comes as the Biden administration ramps up its messaging for Americans to get vaccinated and receive their booster shots.

The Omicron variant of the novel coronavirus on Monday became the dominant source of new infections in the United States, accounting for roughly 73 percent of new infections nationwide, according to data from the Centers for Disease Control and Prevention (CDC).

Federal officials cited CDC figures for the week ending Dec. 18 that showed a nearly six-fold increase in Omicron’s share of infections in only one week.

Infectious diseases expert Dr. Anthony Fauci on Dec. 17 floated the idea of redefining what it means to be fully vaccinated in the United States.

Currently, individuals are considered fully vaccinated after taking their second dose of a two-dose series, such as the Pfizer-BioNtech vaccine, or after a single-dose vaccine, such as the Johnson & Johnson vaccine.

However, Fauci told CNBC’s “Squawk Box” last week that a redefinition of being fully vaccinated is “on the table.”  “There’s no doubt that optimum vaccination is with a booster,” he said.

“Whether or not the CDC is going to change that, it certainly is on the table and open for discussion. I’m not sure exactly when that will happen. But I think people should not lose sight of the message that there’s no doubt if you want to be optimally protected, you should get your booster.”

The Court of Appeal rejected the application of the “derivative injury rule” to limit the tort claim of the spouse of an injured worker who suffered an admitted workplace COVID injury,  The spouse was infected when the worker returned home from work, and later died from the COVID infection. Thus the exclusive remedy provision does not protect employers from these related tort claims.

Matilde Ek, a worker at a See’s distribution center in Southern California, contracted COVID-19 and apparently infected her 72-year-old husband, Arturo, who died. Ek said she worked on the See’s packing line without proper social distancing or other protections even though some workers were coughing, sneezing and showing other signs of COVID-19 infections.

She and her daughters sued See’s, alleging that since her workplace lacked sufficient safeguards against infection, the company is liable for his death.

See’s acknowledged that Ek’s illness was job-related but argued that since it was, the company was protected from liability for her husband’s death under the “exclusive remedy” doctrine.

Los Angeles Superior Court Judge Daniel M. Crowley refused to throw out Ek’s lawsuit, agreeing with Ek’s attorney that her husband’s death was a separate event from her workplace infection.

And the Court of Appeal affirmed the trial court in the published case of See’s Candies, Inc. v. Super. Ct. (2021).

Defendants argued plaintiffs’ claims are barred by the “derivative injury doctrine” (see Snyder v. Michael’s Stores, Inc. (1997) 16 Cal.4th 991, 1000 (Snyder)), under which “the WCA’s exclusivity provisions preempt not only those causes of action premised on a compensable workplace injury, but also those causes of action premised on injuries ‘ “collateral to or derivative of” ’ such an injury.’ (King v. CompPartners, Inc. (2018) 5 Cal.5th 1039, 1051 (King).) Among other things, this doctrine preempts third party claims “based on the physical injury or disability of the spouse,” such as loss of consortium or emotional distress. (Cole v. Fair Oaks Fire Protection Dist. (1987) 43 Cal.3d 148, 162-163.)

In rejecting this argument the Court of Appeal said that “Snyder approved of cases applying the doctrine to claims by family members for losses stemming from an employee’s disabling or lethal injury, such as wrongful death, loss of consortium, or emotional distress from witnessing a workplace accident. In contrast, the Supreme Court called into question a case applying the derivative injury doctrine outside these contexts based on causation alone.”

However, this decision is just a small part of the case which has yet to be litigated. The Court of Appeal noted “we have no occasion to decide whether defendants owed Mr. Ek a duty of care or whether plaintiffs can demonstrate that Mr. or Mrs. Ek contracted COVID-19 because of any negligence in defendants’ workplace, as opposed to another source during the COVID-19 pandemic. The parties have not raised these issues, and we decline to address them sua sponte.”

The Supreme Court received at least 11 emergency applications on Monday challenging the federal mandate for businesses with over 100 employees to require Covid-19 vaccinations or weekly testing according to a report by Courthouse News.

Enforced through the Occupational Safety and Health Administration, the mandate was reinstated on Friday when a Sixth Circuit panel overturned what had been pause on the nationwide rule imposed by a federal judge. It is set to take effect on January 4.

The groups challenging Biden’s mandate include conservative groups like the Heritage Foundation, 27 states, business associations like the National Federation of Independent Business and the Job Creators Network, BTS Holdings, religious groups like the Word of God Fellowship and the Southern Baptist Theological Seminary, companies like Phillips Manufacturing and construction workers. Most of the groups are challenging OSHA’s authority to enforce the mandate while others are also alleging violations of the First Amendment and religious freedom.

Without a stay from the high court, the mandate would affect about 84 million workers and require unvaccinated employees to wear face masks and be subject to weekly testing for Covid-19.

Ohio is at the helm of the pack of 27 Republican-led states claiming that the mandate is unprecedented and that OSHA does not have the authority to enforce it because Covid-19 is not an occupational danger that the agency can regulate, the virus does not present a “grave” danger, and the mandate does not satisfy the emergency provision requirement.

The National Federation of Independent Business claims the mandate will cause “irreparable harm” on hundreds of thousands of businesses and will cause a devastating labor upheaval.

The religious organizations are challenging the mandate because it does not offer accommodations required by the Religious Freedom Restoration Act of 1993.

Some of the organizations – like BTS Holdings – say Congress did not grant OSHA the powers to authorize the mandate and if it did it would be violating the constitution.

Friday’s majority opinion by U.S. Circuit Judge Julia Smith Gibbons said that the mandate was “not a novel expansion of OSHA’s power” and that the agency had the authority to regulate infectious diseases not unique to the workplace.

“Vaccination and medical examinations are both tools that OSHA historically employed to contain illness in the workplace,” the Bush appointee wrote.

OSHA first announced the mandate in November. The Fifth Circuit had granted a stay to BTS Holdings in its challenge against the mandate, but the onslaught of challenges filed across the country triggered a lottery process and the cases were assigned to the Sixth Circuit for all further proceedings.

Monday’s stay applications were submitted to Justice Brett Kavanaugh, per court rules, and a response from the Biden administration is due by Dec. 30.

The administration has other vaccine mandates that are being challenged in court, and the high court has seen multiple challenges on vaccine mandates come across their docket this year already. So far, the court has turned down relief for workers seeking religious exemptions. Last week the Fifth Circuit overturned an injunction on a vaccine mandate for health care workers in federally funded facilities.