REVIEW - Amazon S3...on international collection companies to reach across borders to recover money they feel is owed to them by foreign travellers and their insurers. The companies,

REVIEW

COST CONTAINMENT

OCTOBER 2011

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collection

overcharge

discount

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ITIJ REVIEW | COST CONTAINMENT | OCTOBER 2011

REVIEW | COST CONTAINMENT

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Welcome to ITIJ’s Cost Containment Review 2011 – our sixth annual publication dedicated to those who work tirelessly to contain costs in all areas of the travel insurance and assistance sectors. This year’s o� ering includes expert opinion pieces from those intimately involved in the cost containment industry, news and analysis of the latest trends and problems the sector faces, and a focus on the di� culties of cost containment for providers of international private medical insurance in Asia. We also take a look at recent developments in European legislation and how it has a� ected the insurers of those patients carrying European Health Insurance Cards; we consider the rami� cations of New York State hospitals’ latest e� orts to claw back some cash; and analyse the di� erent ways in which insurers can protect their bottom line from major medical claims.Exclusive to the Review, an international claims management company o� ers its own expert views on what can be done to best combat the problem of fraudulent travel claims. We have also included an article that shows how the cost of air ambulance � ights can be kept to a minimum, while still ensuring the best possible patient care. And rounding o� this year’s Review is an interview with Magdi Riad of SelectCare Worldwide, who has some interesting ideas for the future of the cost containment industry, and the wider travel insurance sector.

Sarah WatsonEditor, [email protected]

Welcome

Learning to love themDebt collectors are now a fact of life

¡Hola hospitales!Spanish hospitals pursue those insuring EHIC holders

A New York state of mindUS hospitals are focussed on taxes

Through the looking glassPricing transparency examined

Working under the radarSavings from fraud detection can be significant

Reinsurers get in on the actThe proactive pursuit of funds is becoming more commonplace

Contents

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14 20

24 28

30 32

The art of negotiationNegotiating the price before you need the service

Keeping a lid on itAsian medical care costs more now than ever before

Contact:

Editorial:+44 (0)117 922 6600 ext. 3Advertising:+44 (0)117 922 6600 ext. 1 Art Department:+44 (0)117 929 4636Fax:+44 (0)117 929 2023Email:[email protected] Web:www.itij.co.uk

Published on behalf of Voyageur Publishing & Events LtdVoyageur Buildings, 43 Colston Street, Bristol BS1 5AX, UK

The information contained in this publication has been published in good faith and every e� ort has been made to ensure its accuracy. Neither the publisher nor Voyageur Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or � rm mentioned, is hereby excluded.

Printed by Pensord Press LtdCopyright Voyageur Publishing 2011Materials in this publication may not be reproduced in any form without permission.

INTERNATIONAL TRAVEL INSURANCE JOURNAL ISSN 1743-1522

Editor-in-chief:Ian CameronEditor:Sarah WatsonCopy editors:Mandy Aitchison, James Paul WallisDesigners:Eli Butler, James ElliottProduction managers:Kate Knowles,Helen WattsAdvertising sales:David Fitzpatrick,James Miller



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A s American hospitals struggle to stay pro� table, they are solidifying, and in some cases increasing, their reliance on international collection companies

to reach across borders to recover money they feel is owed to them by foreign travellers and their insurers. The companies, some of the major ones based in the UK, Switzerland and Israel, as well as the US, are responding to hospitals desperate to � nd new sources of revenue to make up for uncompensated care losses that now exceed $40 billion annually, approximately six per cent of their total expenses.

Weapon of choiceFor hospitals in tourist-rich areas, services to foreign patients can amount to a substantial share of their revenues and costs, and when patients return home leaving unpaid or underpaid bills behind, collecting is a lot tougher than it is from domestic patients. Consequently, the hiring of international collectors accustomed to working across borders has become the method of choice for many hospitals dealing with delinquent foreign medical claims or ones they feel have been unfairly or inappropriately settled by insurers or their cost containment representatives. The collection companies, among them Ovag International AG, based in Lucerne, Switzerland; Gallagher Associates Ltd International, based in Kent, UK; Global Recovery Alliance, AG, based in Zurich, Switzerland; BDM International Collection Services, based in Tel Aviv, Israel; and Medassets, based in New Jersey, US; are all well-positioned to o� er US hospitals not only hardcore collection services, but accounting and auditing mechanisms to help them determine when and if they have been underpaid, or when international insurers have been given discounts to which they allegedly weren’t entitled. The remedy in such cases is to go after the foreign patient and/or his insurer with a demand to

balance the bill – in e� ect, to pay the di� erence between what the insurer or its cost containment representative has already paid after negotiated discounts have been applied, and what the hospital originally billed. Hospitals and their collector surrogates know that if they put pressure on the patient, the underwriter will pay because it becomes a public relations issue. The last thing an insurer wants is to have his policyholder deal with intimidation from a collector. And hospitals have found that by partnering with foreign collection/recovery � rms who have an international reach and whose expertise lies in cross-border recoveries – in the patient’s native language, with the ability to impact their credit standing and even hit them with court-ordered judgments to pay up – they have gained access to substantial sources of revenue. Collection companies can work in several ways: they can buy debts from hospitals outright and whatever they collect remains theirs. Or they can work on a fee, generally 25 or 30 per cent of what they collect – so that if a hospital has already received $10,000 on a bill and the collector o� ers to collect the remaining $90,000, keep a third, and pass the remainder on to the hospital, why not?

Howard Dorsky, chief business o� cer and system director for the Spring Valley Medical Center in Las Vegas, US, an area known for its high density of foreign tourists, says: “We either try to collect the outstanding debt before they [foreign patients] return to their home country or we have to place their accounts with foreign collection agencies … unfortunately, we have to use these agencies as we have no other means of obtaining the debt once the patient leaves the US.”He adds that in such cases: “The agencies will be soft in the beginning, letting them (the patient) know that they represent us and that a balance is due. There is no hardcore collection e� ort made until the agency feels that the patient is not co-operating with them and (then) they will do what they have to in order to collect the monies due on our behalf. Our approach is soft and will get stronger if the debt is not being paid or the patient is ignoring the balance owed.”

Cause and effectBut why does this happen? Why are collectors necessary once a foreign patient’s insurer or cost containment representative has ‘settled’ the bill on behalf of its client? Isn’t that what people buy travel insurance for?Many US hospitals contend that some cost containment companies representing international insurers dig too deeply for discounts to which they are not entitled. They say insurers or their cost containment representatives sometimes use large domestic insurance companies (United Healthcare, Cigna, Aetna, Blue Cross/Blue Shield) and ‘silent’ PPOs as surrogates through which they receive the deep discounts to which only the large companies with the power to ‘steer’ high numbers of patients are really entitled. Hospitals also contend that foreign insurers are not entitled to the discounted DRGs (diagnosis-related groups) or Medicare rates that are heavily subsidised by domestic taxes – levied on

Many US hospitals contend that some cost containment companies representing international insurers dig too deeply for discounts to which they are not entitled

Milan Korcok believes that, love them or hate them, cost containers must learn to live with international bill collectors

LEARNING TO LOVE THEM

ITIJ REVIEW | COST CONTAINMENT | OCTOBER 2011 |


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Americans for Americans. Yet many international cost containers feel these fees are fair recompense for hospital services and see no reason not to demand them.Udi Ben-Gal, director of operations for the Tel Aviv-based collection company BDM Ltd., in a prior interview given to ITIJ, explained that all US hospitals will gladly accept payments that are based on PPO rates, but many insurers want better than that. “They try to play it both ways,” he said, demanding Medicare rates o� ered to domestic insurers but without o� ering the great volumes of patients the Medicare system provides.However such arguments play out, they re� ect the major disparity between what an insurer sometimes pays for a given set of hospital services, and what the hospital thinks is fair, and that is a gap international collection companies are prepared to explore. Medassets, one of the largest of the US-based recovery companies, o� ers client hospitals a broad range of recovery services well beyond hardcore collections. Its website promotes services including: auditing zero-balance accounts to identify and recover inappropriate managed care network and payer discounts; probing violations of contractual terms by payers; recommending contract language to close o� silent PPO loopholes; recovering cash from inaccurately paid contracts; even using managed care experts and clinicians to recover losses due to denials.

ExamplesLast year, Medassets demanded that its client, Lakeland Regional Medical Center, in Florida, US, should be reimbursed by a Canadian insurer to the tune of $34,217 for a discount it gained through the Hygeia Travel Health PPO. Medassets claimed that the contract between Hygeia and Lakeland hospital required the presence of the Hygeia logo or name on the member’s identi� cation card. It concluded: “Because the Explanation of Bene� ts shows the discount was taken through Hygeia

Travel Health and the member’s ID card does not reference the PPO, the discount is not allowed.” The discount was taken o� a $96,343 bill that was purportedly settled four years earlier. In this case, the insurer was ultimately held responsible for paying the amount.In a similar case, Medassets demanded a Canadian insurer pay Tampa General Hospital $17,008 it received as a discount through the First Health PPO network because the plan did not include the incentives necessary (deductibles, co-payments) to redirect the plan member to Tampa General Hospital. The original bill was $22,608 and the insurer paid $5,600 in what it thought was total payment. But Medassets concluded, on behalf of its client: “It is the strict policy of Tampa General Hospital to not honour discounts taken through First Health in the absence of patient redirection incentives, which are designed to ‘steer’ plan participants to in-network providers in exchange for preferred reimbursement rates.” Notably, though this bill was three years old when Medassets detected the discount discrepancy, it was free to follow it up for collection under statutes of limitations, which in some states can run up to seven years – long after insurers have closed their books on those accounts.

Unfortunately, the contract under which the PPO had o� ered the discount to the insurer did not guarantee it, (a common practice for PPOs and TPA that o� er ‘savings’ to insurers): a situation that sometimes leads to the insurer not only being left on the hook to the hospital for the retroactively disquali� ed discount, but for the ‘savings’ fee, which it long ago paid the PPO or TPA intermediary for getting the discount. Caught both ways.

Keeping it on the QTIt’s hard to document how widespread the use of collection practices really is. Hospitals don’t like to talk much about collecting procedures or forcing their own patients into foreclosures or bankruptcies. And in fact, many state governments have restrained hospitals from billing uninsured or indigent patients, requiring them to disclose their charity care options, to o� er � nancial assistance plans to low or even some middle-income families, and to charge the uninsured or underinsured no more than they do their large insurers. In California, hospitals may not send a bill to a collection agency if the patient is attempting to qualify for � nancial assistance or negotiate a payment plan. But the safeguards given to domestic, indigent or uninsured patients don’t hold for foreigners vacationing in the most favoured US tourist locations under the cover of international travel insurance.As for international cost containment companies, they generally don’t like to talk at all. We contacted three of the largest with questions concerning the number of hospitals they deal with and why hospitals use their services (Gallagher Associates in the UK, Global Recoveries International in Switzerland, and Medassets in New Jersey, US). None responded to any of our emailed questions.What do cost containment professionals feel about the intrusion of collection agencies into the insurer-hospital-patient relationship?

there does appear to be an increasing trend among some hospitals in Nevada (Las Vegas) and Florida, particularly, to refer all their foreign bills to international collectors

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Magdi Riad, president of SelectCare Worldwide, feels the international collectors ‘are somewhat useless to an insurance company’, acting as a barrier between the payer and the healthcare provider. He adds that their contact with hospital personnel ‘is usually at the junior level and payer issues are never communicated to senior executives who can make sense of any given situation’. “In my opinion,” says Riad, “hospitals are doing a disservice to themselves by using these collection agencies when it comes to insurers.”He adds also that a new wave of collectors is now being seen as lawyers enter the collection market. “They are the worst collectors. To justify their fees, they in� ate the invoice with interest and threaten (only threaten) litigation. I personally think using lawyers to collect a hospital account will create a lot of litigation, and verdicts will create precedents against hospital practices and excessive charges. Not very smart.”Patrick Hrusa, head of operations at WTP Assist, believes the use of international collection companies by hospitals appears ‘to have reached a steady base level’, but is growing along with the underlying claims pool. J. Ross Quigley, chief executive o� cer of Medipac Assist, says the use of debt collectors and lawyers as the ‘� rst contact’ for foreign hospital bills appears to have been a trend that is disappearing as it caused a backlash ‘with payers and clients who generally refused to deal with these people’. However, though there is less harassment of

clients about balance bills, there are still lots of them being sent out, says Quigley: “We (tell) our clients simply (to) refer all calls on bills to Medipac Assist.” He notes also that there seems to be little commonality about the way hospitals control ‘the harshness and aggressiveness of the collection process for that speci� c hospital’. And whether or not hospitals are part of a larger group doesn’t seem to make a di� erence. “With some we have excellent relationships … others seem to be

operating in the dark ages, i.e. club your client and/or payer into submission.”Juliann Martyniuk, product manager of travel insurance and a� nity markets for Manulife Financial, one of Canada’s largest providers of travel insurance, reports that there is no recent evidence of increased collection activity, referrals to collection, or attempts at balance billing, but where collections are seen, ‘Swiss companies appear to be the most aggressive’.

Martha Turnbull, head of auto, travel and property claims for RBC Insurance, says there does appear to be an increasing trend among some hospitals in Nevada (Las Vegas) and Florida, particularly, to refer all their foreign bills to international collectors, and she admits there are some patients being harassed by collectors trying to balance bill, but ‘if we have the information from the collection agency, we try to resolve the issue with the provider,

network and collector involved’.Some international travel insurers and their cost containment representatives have characterised US hospitals as greedy and uncompromising, driven by unrelenting demands of stockholders whose sole pre-requisite is pro� t – even though barely 20 per cent of the nation’s hospitals are investor owned, for-pro� t institutions. They say hospital ‘chargemaster’ price lists are arti� cial and have no relationship to the cost of the goods and services they provide. And so they feel justi� ed in drilling down to get the best possible ‘deal’ for their insured clients as they can. But how long can that continue without consequences? And, is the use of harsher, more aggressive collection tactics and the enlistment of professional cost collection companies not the inevitable response? Perhaps the hardest reality foreign insurers must face is that by covering their clients for medical services in the US, they are de facto stakeholders in the most expensive healthcare system in the world and the cost of playing in this game is very high. They are players in a very tough league. No favours given. n

However such arguments play out, they reflect the major disparity between what an insurer sometimes pays for a given set of hospital services, and what the hospital thinks is fair

Milan Korcok is an award-winning freelance health policy and economics writer who covers travel insurance, public health, and medical education issues in Canada

and the US. He has been writing about health financing and policy issues in these countries since the 1960s, and is a frequent contributor to leading North American professional journals and consumer media.

Author



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The creation of the European Health Insurance Card (EHIC) has its origin in the action plan approved at the end of 2005 by the Barcelona European

Council to suppress obstacles to geographical mobility. The card replaced various paper forms such as the E111 (for a temporary stay on account of a trip), E128 (if moving to a European Union (EU) member country for work) and the E119 (covering travel for employment).It is important to remember that the card is for the individual use of each patient and is valid for up to � ve years from the date of issue. In cases where the patient is not carrying an EHIC, an alternative document exists called a ‘provisional replacement certi� cate’. This document is equivalent to the EHIC and acts as a replacement if the cardholder has lost or forgotten their card, or if their homeland social security department is unable to issue the applicant with an EHIC prior to their departure. New EU legislation came into being on 1 May 2010, however, that has had an e� ect on social security regulations, and which, in the case of Spain, gives further legal basis for the new management procedures adopted by Spanish hospitals for the recovery of costs relating to foreign patients. These new regulations include Regulation (EC) 883/2004, which focuses on the co-ordination rather than the harmonisation of EU member states’ social security systems, thus respecting the characteristics of national social security legislation.

Tourism boomTo understand the impact of the cost of treating foreign visitors on Spain’s economy, it would be prudent to look at inbound tourism � gures. The importance of tourism for Spain is beyond doubt, and is a major source of income in the country’s

balance of payments. It is also an important engine of national development in all aspects, but is closely linked to infrastructures that include building new hospitals and medical centres.New data from the ITE (Institute of Tourism Studies), in its section ‘FRONTUR’, shows the recovery of tourism in Spain, with the usual tourist and destination pro� les maintaining their prominent poll positions. Thus, the UK, France and Germany make up the largest source

markets of tourists. Catalonia, the Balearic Islands and Andalucia are, in this order, the major destinations. In August 2011, Catalonia received just over 24 per cent of the country’s total international tourists – a � gure that was up almost three per cent on last year’s � gure. The Balearics received almost 24 per cent of total arrivals – up 8.5 per cent; and Andalucia attracted just over 14 per cent – up � ve per cent. This equates to 7.64 million tourists visiting Spain in August 2011 – up 9.4 per cent on August 2010.

Preparation is keyThe European Commission’s Directorate-General for Employment, Social A� airs and Inclusion states on its website: “Medical ethics dictate that a doctor cannot refuse to treat you if your state of health requires treatment. However, there is no guarantee that your costs will be reimbursed under the same conditions as if you had been able to prove that you had social security insurance at the time by presenting the card or an equivalent document. The doctor or medical establishment might well ask you to pay the full cost or to pay up-front a proportion of the costs, which an insured person in that same Member State would not be asked to pay. In an emergency, your local health authority might be able to help by faxing or emailing you a provisional replacement certi� cate, which gives you the same protection as the European Health Insurance Card.” In this context, what must be taken into account is the impact of data protection law in Spain, which is the most restrictive in Europe. The fundamental signi� cance of this is that the EHIC and its data can only be provided by the patient or a family member or legal guardian and only during the hospital stay. Also of note are � ndings from a recent survey detailing travellers’ knowledge regarding the EHIC. A recent Eurobarometer survey – commissioned on behalf of the European Commission – shows that people are not always aware of the EHIC, even if they have one. Twenty-six per cent of respondents say they have an EHIC, compared to 37 per cent of the population who actually hold a card. This � gure could, however, be a� ected by the fact that in Austria, the Czech Republic, Italy and Switzerland the EHIC is issued automatically to all people insured under their state social security. Furthermore, those having lived, worked or studied abroad

Hola hospitales

Spanish hospitals have been in the spotlight recently for their use of private collection agencies to recoup the cost of treating foreign patients from international insurers despite the production of an EHIC. Dr Pablo Gonzalo looks at how new EU regulations could bolster Spain’s existing laws that allow hospitals to pursue third parties obliged to pay

Twenty-six per cent of respondents say they have an EHIC, compared to 37 per cent of the population who actually hold a card

¡ !

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will also have likely been issued with an EHIC. Asked why they do not hold an EHIC, 68 per cent of respondents without the card say they have never heard of it and know nothing about it. The next most frequently given reason is that people have separate travel insurance and therefore do not need an EHIC (11 per cent). Five per cent of respondents said they could not be bothered with it, and the same proportion feel they do not need an EHIC because they can be reimbursed for health costs without it.Of those who do have a card, two-thirds always take it with them when travelling in Europe. The most common reason for not taking the card is forgetting it at home (28 per cent of those who did not take it with them).

Source of conflictThe situation in Spain is the same as that in other EU countries: all hospitals within the public network have an obligation to treat those EU travellers presenting the EHIC, as a general principle. To

understand the current situation in Spain, however, one needs to look at the di� erences between the various regions (autonomous communities), as well as the di� erent models of � nance.The health expenditure generated by the EHIC is transferred from the treating hospital in whatever region, to the International Social Security Agency (ISSA) based in Madrid, which generates the invoices to be charged to the health authorities of the patient’s home country. It also receives the funds for such assistance, which are sent back to the health delegations in each region. Under no circumstances does the treating hospital receive those funds unless the patient or their insurance company can be charged directly.The management model in the country’s hospitals has also varied during recent years – from those hospitals based purely on the public model, to those that are managed privately, and those that are managed by public companies. With all of them, the Ley General

de Sanidad (Article 83) forces the hospital to charge health expenditure to the third parties obliged to pay – which is the main reason behind the con� icts currently seen emanating from the country with regards to the billing of international insurers for the treatment of those insureds carrying an EHIC. In their interpretation of the Spanish law, some public hospitals – including those with private management (and following the mandatory regulation to charge the health expenditure cost to third parties, as well as the current need to compensate the public debt) – have developed strategies to recover the costs incurred from the treatment of EU travellers, even those presenting the EHIC. This is happening in the Balearic Islands, Catalonia, Valencia and Andalucia. However, it does not apply to other regions such as Madrid, Galicia and Castilla-Leon, where the card is accepted as an instrument of guarantee and payment.Those hospitals chasing payment from a third party have either opted for direct processing through their third-party billing department (such as at Hospital Son Espases in Palma de Mallorca) or have chosen to outsource this process, hiring private agencies (such as Gestitursa or Global Medical Care).When queried, the International Social Security Agency in Madrid said o� cial agencies such as itself only establish the obligation of hospitals to accept the EHIC and treat the patient according to the severity of the illness until the patient can return to their country of origin; but they do not evaluate whether a hospital has the right to recover their costs, as this is the remit of the Ley General de Sanidad. All things considered, the current climate of con� ict between assistance companies, insurers and some

hospitals in the public network – with their related agencies, new European regulation that in theory extends social security coverage and data exchange, as well as institutions and hospitals seeking to reduce the de� cit by squeezing domestic legal possibilities – is not surprising. Fortunately, the new EU regulation, in anticipation of potential irregularities in its implementation, established a monitoring and arbitration commission. This commission is called SOLVIT and all information concerning its activities can be found on the European Commission’s website at www.ec.europa.eu/solvit.The Commission’s decisions are not binding, but do serve as the basis for decisions made in the European Court of Justice. In the future, and following the resolution of complaints now forwarded to the relevant authorities, as well as claims � led by hospitals in cases of non-payment by insurers, we will see how SOLVIT and the European Court of Justice settle the situation.At the end of the day, international law establishes the supremacy of European regulation over each country’s law, so the general recommendation is that patients always travel with their EHIC and present it to the admission services every time they need medical care in the Spanish public healthcare system. n

All things considered, the current climate of conflict between assistance companies, insurers and some hospitals in the public network … is not surprising

Pablo Gonzalo was born in Madrid in 1967, and began working as an emergency doctor in Madrid in 1991. He specialises in air rescue, IT solutions, and is a member of

the Emergency Spanish Medical Association. He began working as a medical co-ordinator at MAPFRE Assistance in 1996 and was promoted to medical director in 1998. Since 2002, he has been the medical director of MCI.

Author



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New York hospitals, and indeed the vast majority of hospitals in the US, are at the epicentre of the same general � nancial crises and economic

meltdown being experienced around the world. In part, this is fueled by the inherent nature of the US healthcare system, with its maze of intricacies and complexities. Hospitals in the US, as is the case in every country, whether private or state run, are, quite simply, ‘struggling’ to survive. Compounding a multi-factorial problem is the often-underestimated role played by the international medical travel insurance industry, especially so for the high tourist destination states of New York, Florida, California, Arizona, Texas, Nevada, and many others, although to a lesser extent.

Some of the factors for which international payers are being blamed include:• The use of silent preferred provider

organisations (PPOs);• The questionable practice of using US domestic

networks whose contract is between the domestic US network and a given US hospital provider, and whose contract is not intended for use by an outside international insurer;

• Purposely withholding payments until a hospital succumbs to a tendered, ridiculously low reimbursement, and on which the hospital invariably loses money;

• The false portrayal of a claim being denied to coerce an unfair settlement from a medical provider, when the claim is in fact payable;

• Supposedly claiming knowledge of what the hospital’s costs are, and then unilaterally by some

arbitrary calculation, dictating how much the hospital should be reimbursed;

• The accessing of a US insurer’s domestic rates of reimbursement in order to obtain the ‘best possible discount’, which was also never intended for international patients to access; and

• Transgression of US unfair business practice citations and fraud laws, such as falsely claiming a low policy maximum, or even deceitfully claiming the patient to be deceased.

Claiming the cash backThe above are but a few practices that illustrate how our industry has contributed to the inevitable – that hospitals, through their state governments, and in a number of other enforcing ways, are reclaiming short repayments on bill charges that have been inappropriately taken or withheld.The State of New York is currently focusing on its state surcharge taxes applicable to medical services rendered in the vast area under its jurisdiction. Other US States – for example, Massachusetts and Minnesota – have followed suit, and these states are seen as the forerunners of a more organised attack against some of the abovementioned practices. As state initiatives move to maximise collections from insurance payers, many more US states are expected to join the example set by New York.The New York State Department of Health has adopted an aggressive audit process to ascertain whether insurance payers (irrespective of being domestic or international) have accurately paid, or not paid at all, the mandatory New York State Surcharge Tax on medical services. What this translates into for international insurance payers

The HCRA Legislation stipulates and makes very clear that all insurers, underwriters, TPAs, assistance companies, or any other organisation working on behalf of a primary insurer, has two options to pay the surcharge

A New Yorkstate of mind

Shaun Plotkin explains the complexities of the New York State surcharge, and the repercussions it has for international insurance companies trying to negotiate astronomical hospital bills on behalf of their clients



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is the creation of an environment of � nancial chaos, especially so if claimed amounts have been paid through the use and instruction of any of the abovementioned conduits. In addition to the well-documented pitfalls associated with these modalities of bill settlements, almost without exception, and by their very nature, the above named settlement methods all inherently ignore the applicable charges due under the New York State Surcharge Tax Legislation. It is claimed by the New York authorities that every patient’s bill emanating from a New York hospital, clinic, surgery centre, or the like, governed by the same Health Care Reform Act of 1996 (HCRA) and its subsequent amendments, will be subjected to an audit, and for which the New York State Department of Health, under the New York State Statute of Limitations Legislation, has up to six years to conduct. The HCRA Legislation stipulates and makes very clear that all insurers, underwriters, TPAs, assistance companies, or any other organisation working on behalf of a primary insurer, have two options to pay the surcharge:• Either as an elector who is enrolled and conforms

to the stringent requirements of an elector on the New York Electoral Roll, and who is then favoured with a lower surcharge reimbursement rate of 9.63 per cent of the original total billed amount, or,

• As a non-elector, who is then required to submit the surcharge over and above the original billed amount, directly to the hospital, at a much higher rate of 37.90 per cent of billed charges.

The six-year statute of limitation period gives New York hospitals ample time to claw back and reclaim funds on accounts where the surcharges were either not paid at all, or incorrectly paid. Certainly, most international insurance payers with past patronage at a New York hospital will by now have been the recipient of demand letters from that hospital, claiming back any unpaid or

recalculated surcharge tax amount. To compound the problem, a discovery of an underpayment of the HCRA surcharge is just the beginning.

PenaltiesIf an audit reveals that the payer has paid less than 90 per cent of what should have been paid as the surcharge, then the payer must pay an additional de� ned interest amount on the di� erence. If the audit reveals that the payer has paid less than

The six-year statute of limitation period gives New York hospitals ample time to claw back and re-claim funds

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70 per cent of what should have been paid as the surcharge, then the payer must pay an additional de� ned interest rate amount on the di� erence, plus a superadded additional penalty of � ve per cent on the di� erence for each month overdue. In a merciful act of comprehending what this might cause to insurance payers, New York authorities have capped only this latter superadded additional penalty tax at 25 per cent. Given the fact that audits can cover a preceding six-year period,

non-payments or underpayments combined with associated added and superadded penalties will no doubt result in very signi� cant charges being owed.From a cost containment and claims settlement perspective, an insurer or assistance company now has to justify to their principal payer/underwriter that signi� cant funds are owed on a claim that was thought to be paid and closed, as far back as six years ago. Of cardinal impact and totally unaccounted for, is that

if the State Surcharge Tax is not dealt with in an appropriate manner at the time of settlement, insurers cannot accurately report their underwriting cycles, pro� t/loss statements can never be accurate, and the combination of the base surcharge tax, together with the interest and penalties owed, will often translate into more than the actual total original billed amount for the medical service that was rendered. Frighteningly, instances of this exact

circumstance are currently permeating and plaguing our industry.Ultimately, this has to translate into the costs of travel insurance premiums rising substantially in order to o� set these additional hitherto unknown liabilities to underwriters of medical travel insurance. The domino e� ect is of course the impact on a vast stratum of people having limited budgets and means to purchase travel insurance, and indeed now with these added costs, being

Now more than ever, the time has arrived for every insurer’s cost containment provider … to be held accountable for their involvement



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Shaun Plotkin holds a bachelor of arts degree from the University of Victoria, a bachelor of laws degree from Monash University, Melbourne, Australia, a graduate diploma of legal practice from the Victorian College of Law, Melbourne, Australia, and is admitted as a barrister and solicitor of the Supreme Court of Victoria, Australia. Shaun is a senior director of Dr Colin Plotkin & Son’s Consulting Inc. His portfolio includes adherence to all contractual obligations, all statutes of limitations are complied with, all negotiations are reached reasonably and fairly, and that Dr Colin Plotkin & Sons Consulting Inc. maintains its professional integrity and position as a leader in the cost containment environment.

unable to a� ord to travel at all. Now more than ever, the time has arrived for every insurer’s cost containment provider (who bears no � nancial risk in the claims settlement process) to be held accountable for their involvement. This is, after all, the reason that enables cost containment companies to charge an ‘access fee’ as a percentage of savings o� billed charges, and which service should contractually exonerate the ultimate payer (underwriter) from

any deferred liabilities.If an arm’s length, bona � de, full and � nal bilateral settlement was not reached with the provider of the medical service at the time of settlement, and which included the surcharge tax payment, it becomes only a matter of time that the example set by the State of New York not only exposes an inappropriately taken discount, but also includes vigorous pursuit for the owed state surcharge taxes. n

Ultimately, this has to translate into the costs of travel insurance premiums rising

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eligibility and claims data (medical, pharmacy and dental) and are used to report cost, use and quality information. The data consist of ‘service-level’ information based on valid claims processed by health payers. Service-level information includes charges and payments, the provider(s) receiving payment, clinical diagnosis and procedure codes, and patient demographics.As the argument goes, people know the prices of cars, � at screen TVs, a gallon of ice cream, and a pound of tomatoes before they buy; why shouldn’t they know how much their gall bladder removal will cost before they commit to the operation?That paradigm is simple. But according to cost containment companies serving international travel insurers, when it comes to healthcare, knowing the price of what patients or their insurers are about to buy is anything but simple.

Navigating the mazeRaija Itzchaki, chief operating o� cer of GMMI (Global Medical Management Inc.), a Florida, US-based cost containment company, says that patient-oriented quality and pricing information being provided by state governments is often di� cult to � nd and understand, and usually requires multiple searches on various government websites. But information on discount prices and payment contract rates is even more complicated and ‘not usable directly for making a decision on fair price payment amounts’. She notes that the federal government, which is the largest healthcare payer through programmes such as Medicare, Medicaid, the children’s healthcare programme, and others, publishes its payment rates, and ‘cost containment companies such as GMMI, or even individual consumers, are able to obtain this information, although it is very complicated, de� nitely, not user-friendly’.Any casual survey of state government websites that are purportedly dedicated to ‘price transparency’ reveals they have no consistent or uniform structure and generally require the searcher to have quite an intimate clinical knowledge of the precise procedure they may need, how it may be administered, with or without contrast media, etc., etc. They are not built for the novice. And even if the consumer/researcher does � nd relevant clinical cost comparisons for hospitals in his area, how does he know if the cost for investigation and treatment of an episode of chest pain at Mercy Hospital in Miami (ranging from $8,271 to $14,809) is a better ‘deal’ than the same treatment at University of Miami Hospital (ranging from $15,666 to $31,509) for his speci� c need and condition? The rationale for price transparency/cost comparison sites is predicated on the consumer being able to make well-considered, deliberate choices about when and where to have his or

You’re visiting Los Angeles, home of the stars, and you suddenly get a crushing chest pain. You call 911 and are rushed to the Cedars Sinai Medical Center, where

after a swift consultation, the attending cardiologist refers you for an emergency Percutaneous transluminal coronary angioplasty (PTCA), more commonly known as a balloon angioplasty, to clear a blockage in one of your cardiac arteries.Do you accept the cardiologist’s advice? Or do you ask for a computer terminal so you can check out the prices at other hospitals in the area? If you do, you might � nd that Cedars is likely to bill you US$116,222 (exclusive of physicians’ fees), while the equally prestigious Ronald Reagan-University of Los Angeles at California (UCLA) Medical Center will bill you only $59,546. Of course, you can also go to the Los Angeles County-University of Southern California (USC) Medical Center and be charged but $12,612.

Across the boardThroughout America, in almost every state, ‘price transparency initiatives’ are being promulgated by legislatures, consumer agencies, hospital rating services, health insurers, and hospitals, to encourage those who pay for healthcare services – consumers or their insurers – to � nd or negotiate the best deals they can. The premise is that since most insured individuals and families are covered by employer-sponsored plans that require them to pay a share of costs through deductibles and co-payments, they have ample incentive to shop around and compare

prices, which helps them directly, but also helps moderate the costs of healthcare overall. At least, that’s the theory, originally introduced by federal legislation under the George Bush administration and expanded by the Patient Protection and A� ordable Care Act, signed into law by President Barack Obama in 2010. At this point, over 40 states have established some form of publicly accessible healthcare provider price and/or quality listing comparison websites. Several have also established databases that collect health insurance claims information from all healthcare payers into state-wide information repositories. Known as ‘all-payer claims databases’ or ‘all-payer, all claims databases’, these are designed to enhance cost containment and quality improvement e� orts at all layers of the healthcare spectrum. Payers include private health insurers, Medicaid, children’s health insurance and state employee health bene� t programmes, prescription drug plans, dental insurers, self-insured employer plans and Medicare. The databases contain

Through the looking glass

US hospitals and insurers are making moves towards pricing transparency, but to what effect?Milan Korcok reports on the latest industry developments

Throughout America, in almost every state, ‘price transparency initiatives’ are being promulgated by legislatures, consumer agencies, hospital rating services, health insurers, and hospitals >>



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her bothersome gall bladder removed, or angina permanently treated, or knee or hip replaced based on quality rankings, mortality data, and relevant price information. But as critics of the existing comparison websites have noted, application of these data is di� cult to use, even for domestic insurers. And it certainly doesn’t � t the needs of a European tourist, covered by international emergency-only travel coverage, stricken by chest or abdominal pains while touring the Grand Canyon or Chicago’s Magni� cent Mile.

Made by designTravel insurance is not designed for pre-planned hospital admissions. It does not allow insurers or their cost containment representatives to assess relative values of comparable institutions prior to each emergency admission. It does not allow insurers to ‘steer’ signi� cant numbers of patients to preferred hospitals in return for favourable rates.Of what value, then, is pricing information and price transparency to international travel insurers whose clients’ choices are usually

limited to getting to the closest hospital?Jason Davis, research and development specialist for Global Excel, a Quebec-based cost containment company, says: “Transparency initiatives make sound economic sense in a simple economic model, but the US healthcare system is not a simple economic model, and to date, transparency initiatives have been ine� ective in curbing the cost trend or taming the wild price dispersion/discrimination in the market.” That opinion is borne out by recent studies that have found no e� ect of hospital price transparency e� orts on healthcare cost moderation in New Hampshire or California over the past two years. In fact, economists David Cutler and Leemore Dafny, writing in the New England Journal of Medicine, March 2011, propose the intriguing possibility that transparency can actually lead to rising prices.They note that many proponents of price transparency favour complete disclosure of all prices paid to every provider by every payer for every service. This strategy may have popular appeal ‘because it resonates with a population frustrated by secret deals and payo� s’. But they postulate further: “Consider the case in which a well-regarded hospital contracts with two insurers. Suppose the hospital charges a lower price to

insurer one because otherwise insurer one would steer patients to a di� erent institution. If the hospital must publicly reveal both prices, it will be less likely to o� er the lower price to insurer one because insurer two would then pressure the hospital to lower its price as well.”The likely result is that the hospital doesn’t lower its price to either, even though it would be of bene� t to the hospital and the patients it serves. Cutler and Dafny also cite the frequently-employed Most Favored Nation (MFN) contract agreement, by which a supplier (hospital) formally agrees not to charge a lower price to any other buyer (insurer) in the area. Under this model, if a hospital signs an MFN agreement with insurer two, it could not lower its prices to insurer one without also lowering its prices to insurer two. Again, prices to insurer one would rise. The e� ect, say Cutler and Dafny, is to limit competition among insurers since: “How can new insurers trying to enter a market compete if they if they can’t negotiate lower prices?”The MFN clause has been attracting government attention for generating market or monopoly

power elements that don’t usually result in lowered prices. The US Department of Justice recently � led suit against Blue Cross/Blue Shield of Michigan, in part because it paid some hospitals with which it had MFN agreements higher prices in order to get them to charge its rivals even higher prices, thereby raising costs for everyone.

Seeking uniformityInternational cost containment professionals have for years worked to decode and decipher the arcane rules that hospitals and insurers use to determine fair pricing, usual and customary rates, discount formulae, and preferential contracts. And so, when the movement to pricing transparency began to pick up steam, there was some hope that a more uni� ed approach to hospital pricing might pave the way for more consistent and predictable hospital pricing patterns nationally, or at least regionally.It has not turned out that way.Magdi Riad, president of SelectCare Worldwide, Toronto-based assistance and cost containment company, tells ITIJ that most of the stimulus for pricing transparency is intended to allow uninsured individuals to make informed consumer decisions. But travel insurance clients don’t have the luxury of evaluating and comparing price data, and even insurance companies can’t decipher which procedures or charges (whether separate or bundled), might be necessary to properly treat a patient. He said: “Hospitals have policies to reduce their charges only to uninsured individuals and not to insurers, so they are of no bene� t to insurers – either domestic or international.” GMMI’s Itzchaki notes that the largest private payers such as United Healthcare, Aetna, Cigna and Blue Cross/Blue Shield, are required to send their payment information to data companies, who use it to gather directories that establish usual and customary payment rates. But these are meant to give domestic insurers the ability to set up their out-of-network payments. “It is important to note,

The databases contain eligibility and claims data (medical, pharmacy and dental) and are used to report cost, use and quality information



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however, that international payers, who typically pay 100 per cent of the medical cost [so as to leave the patient with no liability], cannot use this information directly to make payments [as that would leave the patient] responsible for the di� erence between the insurance payment and the billed amount.” Global Excel’s Davis believes that pricing transparency has been e� ective in in� uencing the selection of elective procedures such as cosmetic surgery or laser eye surgery where the customer is the payer. “(But) in terms of whether any of this information is useful or adds value, I would say that it does not help at all … we can already calculate average commercial payments from distilling various publicly available databases. Any payer or cost container (international or otherwise) worth their salt does not really need any information based on the transparency initiatives.”

Government-led changeA major impetus for the expansion of pricing transparency mechanisms for the public resides now in Congress, where both parties are pushing various bills further promoting transparency.

Congressman Frank Pollone, chairman of the health subcommittee of the Committee on Energy and Commerce, reinforces the concern that pricing disclosures have the potential to force vendors in highly competitive, mostly small, markets to match their competitors prices – and that could be upwards, as well as down. But sponsors of most other bills insist that in time, more transparency will lead to lower costs.Several of the bills also call for more transparency around insurer/hospital contracts, requiring not only hospitals to make their charges public, but insurers to reveal what they actually pay for services in any given market – data that traditionally have been guarded jealously by both buyers and purchasers. The American Hospital Association has also advanced proposals intended to open up pricing and payment information to individuals as well as to all payers, but concedes that while sharing prices with consumers is important, it will be a challenge to provide meaningful information to all parties. The AHA calls for making pricing information easy to access and understand, creating common de� nitions and language, explaining why prices vary, encouraging

patients to look at other factors in addition to price, and alerting patients to information about � nancial assistance. It has also called for expansion of reporting requirements to all 50 states.

Fair’s fairMike Starko, managing director of OneWorld Assist, a British Columbia, Canada-based assistance and cost containment company, says that pricing transparency will always be welcome and does provide more context for negotiation. He adds: “However this, in and of itself, does not guarantee reasonable pricing. As provider contracts come up for renegotiation, there is a real push by them to move away from per diem and DRG-type contracts. They want contracts that just have straightforward percentage-o� discounts, i.e., instead of a $1,300 daily per diem rate, they would prefer to just stipulate in the contract that they will give a 40-per-cent discount o� billed charges.”Starko adds: “While the savings rates may continue to be high, payers realise that this does not necessarily mean a fair deal. We look at the lowest net cost of care, which considers the direct cost of care, along

with any savings fees if applicable. While more di� cult to measure and compare, it is a much better indicator of whether or not they received a fair deal.” Jason Davis concurs that discounts are not reliable indicators of a fair deal. “I have paid bills with a 10-per-cent discount that were very fair, and I have paid bills with an 80-per-cent discount (at the behest of our client) where I felt the deal was not fair for the payer.” Raija Itzchaki emphasises that it is necessary to � rst establish whether or not the original billed charges are fair indicators of usual and customary pricing: “It is better to receive a 10-per-cent discount from billed charges of $100 than to get 30-per-cent o� billed charges of $500. Despite its mixed reviews so far, the move to price transparency, by both providers (hospitals) and payers (insurers), is a train that will be hard to derail, because the principle of transparency is so hard to challenge on simple, moral grounds. Who can publicly favour opacity over transparency? To date, the only thing that has been achieved is the basic belief that transparency equals honesty equals good. But making it work for all stakeholders in the US’s contorted healthcare system is quite another matter. n

many proponents of price transparency favour complete disclosure of all prices paid to every provider by every payer for every service



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Uncovering fraudulent activity with regards to travel insurance claims is vital – more so now than ever before. Lynda Calloway and Cath Williams provide an update on the evolving nature of travel insurance fraud and look at the cost savings that can be made if – and when – such endeavours are detected

The opportunity to commit fraud is potentially wider-reaching in travel insurance than it is in other lines of insurance. Furthermore, the cost of a

policy is relatively cheap, so it’s seen as a low-risk and high-pro� t exercise. Fraudsters also play on the fact that insurers � nd it di� cult and costly to prove fraud when the incident took place in another country. However, times are changing and life is becoming much more di� cult for travel fraud perpetrators.Statistics produced by the Association of British Insurers have shown that, compared to other market sectors, fraud in travel insurance is bucking the trend: the overall value of fraudulent claims is falling, but the volume of fraudulent claims is growing. It’s not di� cult to understand why: lower-value travel insurance claims tend to fall under the radar. A stolen handbag, camera or other personal possession would usually amount to a relatively small claim. And they can be time consuming to validate; so long as the supporting paperwork seems in order, the cost e� cient option is to settle. Multiple lower value claims on a range of di� erent policies are also di� cult to detect, and this is another stream of income for those who know how to work the system. An example of this is the couple that were taking regular short

breaks, sometimes with � ights, sometimes not, and were apparently mugged each time, with a variety of low-value items stolen on each occasion. This regular stream of income abruptly stopped when they became over con� dent and submitted identical claims to the same claims management company – one of the products being white labeled; it was then picked up through duplicate matching. This is an all-too-familiar scenario. Fraudulent low-value travel insurance claims range from exaggeration to complete fabrication of the claim, mostly from individuals, but also, increasingly, from organised groups. And it comes from two angles – the customer and, in some cases, the medical providers. Routine screening has to be applied at every level and vigilance is critical. Insurers and claims management companies across the world have access to new and innovative initiatives that tackle this massive area of leakage within the system. But, as most of these claims are low-value, it has to be a low-cost investigative mechanism that’s e� ective and cost e� cient.

Intelligence and profilingRobust screening procedures are a basic must. However, it’s important that they are

A UK claimant submitted 38 baggage claims over a period of nine years, claiming in excess of £75,000 in total. The early losses allegedly occurred on different dates and were as a result of similar mugging incidents and were for similar values. The claims were made against 20 different types of insurance product underwritten by eight different insurers. Viewed in isolation, none of the claims presented concerns over their validity. It was not until the claimant submitted identical claims against five different insurers, one of whom who had identified a previous claim against them, that further investigation uncovered the fraud. The claimant had successfully claimed in excess of £40,000 and was subsequently convicted of 16 counts of theft by deception and nine counts of fraud under the 2006 Fraud Act. He was sentenced to six months imprisonment (suspended for 18 months) and ordered to do 200 hours of community service. NB: 2011 update – this individual is submitting suspect claims again!!

Case A

Working under the radar

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Name, address, telephone, e-mail and other such details can be used to carry out deep Internet searches, including social networking sites. There’s a massive amount of global information that sits behind the Internet and it’s not something you can access via Google or Yahoo; this is specialist work. It’s amazing how much you can pick up from these initial searches and, with no more than a few clicks, otherwise unknown connections between multiple claims can be detected.

Technology and communicationsDevelopments in technology and communications have played a huge part in improving the pro� ling and intelligence process. Translating foreign documentation is now relatively straightforward – anyone with access to a computer and the right software could probably have a go at this, but fraudsters rarely do. We saw one case where a customer – a gentleman who was claiming medical costs for a broken leg – had, according to the declaration from the medical authorities in India, apparently undergone a Caesarean section! Then there’s the added zero to make the claim in the thousands rather than hundreds, but they don’t realise that the sum is written in words, in the local language, elsewhere in the paperwork. Document analysis has become easier to do, utilising tools such as the Visual Spectrum Comparator and Electro Static Detection Apparatus (ESDA). This enables much of the initial detection work to be carried out, forensically,

In 2010, a number of linked claims were identified as having the same email addresses and mobile numbers. These claims were made in different names and addresses but were for similar losses involving suitcases misplaced by budget airlines travelling to the Middle East and Asia. Supporting documentation was found to be false. These claims affected six UK insurers, and while some payments have been avoided, approximately £15,000 has been paid. Investigations are ongoing and additional linked claims are likely to be identified.

Case C

designed with the genuine customer in mind – and the vast majority of travel claims are genuine. Any fraud detection procedures have to be carried out discreetly and quickly, ensuring that there are no delays in the process for honest customers.Claims International in the UK, for example, has access to an intelligence database that holds 10 years’ of suspicious claims data. Every travel claim is checked against some four million records, across a full range of insurance data. A comprehensive screening process such as this enables you to single out any dubious claims at the entry level. Furthermore, the travel insurance industry in the UK is currently working together to develop an industry-wide, cross-insurer claims database – something that has been sadly lacking to date. The tangible � nancial bene� ts of this will be realised very quickly. It’s encouraging to see collaboration in this arena, which will ultimately bene� t both insurers and their customers.Key Investigation Indicators (KIIs) are also basic to the screening process for each travel claim. A series of fully automated � lters make it easy to single out anything that appears dubious and makes the screening process more rigorous. The KIIs are di� erent for each type of claim: cancellation, lost baggage, theft or medical claims all go through a very di� erent process. If a claim goes down the investigation route, desktop intelligence analysts can then take all circumstances from the submitted forms and identify all the vital ‘searchable’ information.

In 2009, a claim was received for cancellation due to gastroenteritis on the date of departure. The British claimant was scheduled to travel to Italy on a booking arranged by a family member via an online travel agent. Through matching of the mobile number, five other claims with different names and addresses, but similar circumstances, were identified. The claims had been made against three different insurance products, but against the same underwriter. Connections between the claimants were also established via Facebook. It transpired that the online travel agent was in fact a bakery and the travel arrangements and supporting documentation were fictitious. The total claimed amount was in excess of £25,000. On investigation, it was established that at least seven other similar claims had been made against other insurers dating back to 2006. Further subsequent claims were submitted and identified in 2010. While claim settlements have been avoided on those claims identified in time, the suspicion is that others have gone undetected.

Case B

fraud detection procedures have to be carried out discreetly and quickly, ensuring that there are no delays in the process for honest customers



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Lynda Calloway joined Claims International Limited (CIL) in 1994 and was appointed claims director in 2002 when CIL became integrated into Cunningham Lindsey

UK. Previously, Lynda was international underwriter at Home & Overseas Insurance Company Limited, which was, at that time, the leading travel insurer in the UK.

Catherine Williams has over 17 years’ experience in fraudulent claims management and specialises in conspiracy fraud investigations. Cath heads up business development activities for Cunningham Lindsey

Investigation Services. Previously, Cath was a claims investigation manager and motor fraud prevention manager with Aviva, and a police officer with Greater Manchester Police.

without requiring the skills of an expert. Needless to say, specialist organisations are still often used to double-check � ndings and deliver ‘expert witness’ evidence where necessary. In addition, Facebook and social networking o� ers a plethora of information that can be turned into evidence and this is proving to be a cost-e� ective and pro-active tool, vital when handling lower value claims. Using an intelligence-led approach to the claim can sometimes avoid the need to send investigators out.Investigative Telephone Interviewing (ITI) is also very e� ective. It’s non-confrontational and adheres to the principles of ‘Treating the Customer Fairly’ throughout. It’s a customer-facing technique and doesn’t detract from the overall customer experience. In one telephone call, a claim that looked very dubious on paper can actually turn into a settlement before it goes further down the investigations route.

Crime connectionsIn the UK, the police force is now more willing to actively investigate insurance fraud because there are proven links between claims fraud and organised crime. The travel insurance industry is learning from the motor insurance sector, where they have a more organised claims fraud footprint: the modus operandi and tactics are broadly the same, and it acts as a fundraising exercise for more serious crimes. Larger, international organisations are also

combining their fraudulent claims data to provide a comprehensive pool of intelligence, identifying individuals who regularly make highly suspicious or bogus insurance claims, across every sector and, increasingly, across the world. Organised fraud is a growing problem. By the compliant sharing of data and intelligence across multiple agencies, we are all becoming more joined up globally, in singling out wider reaching criminal activities. Data sharing is a very cost e� ective way of detecting fraud, and is the only way forward if we, as an industry, want to combat the ongoing and very real threat that fraud has become. n

The travel insurance industry is learning from the motor insurance sector, where they have a more organised claims fraud footprint

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With the di� culties faced by most economies and the travel industry generally, and with the pressure on margins for travel

insurers speci� cally, cost containment is an area that is ignored at an insurer’s peril. We do need to distinguish between ‘cost containment’ and ‘subrogation’, as subrogation is really only one aspect of the cost containment process. The distinction is important, because most other areas of cost containment have been exhaustively pursued. This includes such areas as re-pricing, auditing, priority on risk, coverage assessment, etc. In other words, the areas of cost containment that have been actively pursued are those that more easily � t process-driven assessment and evaluation.Subrogation has, and continues to be, a di� cult

process to manage and assess, as it does not � t neatly into easily identi� able and measureable categories that keep the accountants happy. It simply does not � t well with process-driven criteria. There are underlying reasons for some of these di� culties, for example:• The sometimes long duration of many claims;• The process itself must be tailored on a case-by-

case basis;• Concerns about the insured/injured victim;• Agreement on sharing limited third-party

liability coverage;• The legal costs of pursuing the insured’s claim in a

jurisdiction that does not permit contingency fees;• The potential triggering of a legal expenses claim;• Recovery of outlay without prejudicing the

insured’s claim;

• The potential of adverse publicity or formal complaint by an unhappy insured.

While all of these issues are quite rightly highlighted as potential barriers to the pursuit of subrogation claims, it is only those insurers and reinsurers who are prepared to be a little more � exible and imaginative in their thinking that will bene� t. These potential problems are all surmountable and none should prevent a recovery being made where there is a potential third party in another jurisdiction.

Problem solvingWe therefore need to look at each potential hurdle, understand the issues and � nd a way to overcome them. With reference to the above issues:The sometimes long duration of many claims. It is correct to say that the larger the claim/outlay, the longer the claim is likely to take to settle. However, even if this is correct, should this really stop a recovery being pursued? Just because a recovery might not be made for this year’s � nancial � gures, it will directly impact on the top line when it is made.To be concerned about the length of time a case takes to conclude and to use this as a reason not to pursue a recovery is, frankly, short sighted. When recoveries are being pursued on a contingency fee basis, if legal fees are not being paid on an hourly basis, the length of time a recovery might take is no bar.Furthermore, it must be remembered that each case is fact and jurisdiction sensitive. Even larger recoveries can be made quickly if, for example,

Subrogation has, and continues to be, a difficult process to manage and assess, as it does not fit neatly into easily identifiable and measureable categories that keep the accountants happy

The past year or so has seen a subtle shift by insurers and reinsurers towards a more active and pro-active pursuit of cost containment and subrogation claims. However, it is difficult to gauge whether this is simply paying lip service to something insurers and reinsurers know they should be doing. Costas Andrea has the details

Reinsurers get in on the act



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there can be no dispute on liability and the third-party insurer could save themselves considerable amounts of money (for example in legal costs) if they make a prompt settlement.The process itself must be tailored on a case-by-case basis. It is because each case is fact and jurisdiction sensitive that it is di� cult to � t them into easy tick boxes. However, the main issue here is to gather su� cient information at the outset to enable an accurate assessment of the prospects of recovery being made. This has been achieved by some insurers simply redrafting claims forms in order to capture more information geared speci� cally to recoveries. With the backup of having these claim forms assessed by someone with experience of pursuing foreign recoveries, a streamlined process follows.

Thereafter, the process can be as simple or complex as insurers require. With certain insurer clients, the identi� ed case is simply outsourced and the insurer receives monthly management information in the format they require.Concerns about the insured/injured victim. The insured does have the potential to throw a spanner in the works. However, if the insurer’s outlay is recovered without the insured even knowing about it, then as long as the insurer’s claim was settled without prejudice to the claim of the insured, there should be no problems.Of course, certain recoveries in certain jurisdictions require not only the knowledge, but the active involvement of the insured. Even here, the two problems highlighted above regarding legal costs and/or legal expenses insurance do not arise where the claim can be pursued on a contingency fee basis. Even in jurisdictions that do not permit actions to be litigated on a contingency fee basis, the right lawyers will pursue pre-litigation claims on such a basis. It is only when litigation is unavoidable and where contingency fees are not permitted that an individual approach must be agreed for the case. However, such occasions will be relatively infrequent.The only occasion when there may be an issue that needs to be negotiated with the insured is when the third party has limited liability coverage. Nevertheless, most insureds are reasonable enough

to understand that there is a limited pot, so a compromise will have to be reached. If an insured takes an unreasonable stance, insurers can decide at that stage whether they enforce their policy terms and conditions or to give in to their insured.Finally, despite what many lawyers may say, many recoveries do in fact happen without the insured’s involvement. The lawyers will tell insurers otherwise, though, so they can pick up the injury claim of the insured too and make money on the back of this.In conclusion, while insurers and reinsurers know they could be doing more, they have concentrated on the easier-to-manage cost containment areas at the expense of subrogation, in the mistaken belief it presents insurmountable and expensive obstacles ... it doesn’t. n

it is only those insurers and reinsurers who are prepared to be a little more flexible and imaginative in their thinking that will benefit

Costas Andrea is managing director of Global Recoveries Limited, a company providing contingency fee-based recoveries worldwide and which utilises Costas’

20 years experience as an internationally recognised solicitor specialising in this complex field. Costas provides a risk and cost-free alternative to traditional law firms.

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Paige Schaffer explains how negotiating medical evacuation service prices with air ambulance providers, combined with detailed research into the industry ahead of time, can save both money and lives

Medical evacuation is one of the most costly functions provided by emergency assistance companies. While it’s smart business to shop

around air ambulance companies to � nd the most cost-e� ective service, the process of doing so eats up valuable time the patient may not have.Shopping around is a time-consuming task that involves many detailed factors. Assistance companies have to manually call several providers to obtain a quick view of the company and its services, such as what type of planes, how many, where the company is based, credentials – and then wait to hear back with responses and bids.

ConsiderationsThe three overarching variables are the speed of matching patient with plane, what kind of plane is used, and the cost. The method of prioritising these considerations di� ers with each situation. Questions that should be asked include: What is the pathology of the patient? What is the size of the available plane? Are stretchers and oxygen available? Can we use an empty leg that’s available to save money? How do we � nd that empty leg that might be there in the sea of email alerts?Negotiating fair and e� cient contracts before the air ambulance is actually needed is a plus for both the assistance company and air ambulance provider. Agreeing upon a price based on volume and continued business gives the air ambulance

company business they than can count on in the near future, and the assistance or insurance company isn’t faced with trying to negotiate the best price in a time of need. Not only is it tough to � nd the time during an emergency, but some providers actually raise their rates because they can – after all, they know you need the service.Assistance companies are not just searching for the best price, but also for reputable providers with a proven safety record. Again, this also takes time to investigate, so deciding on which company to work with before you need its skills is invaluable. In order to try and simplify this complex and lengthy process, in 2005, Europ Assistance developed a proprietary air ambulance sourcing tool that noti� es multiple air ambulance

companies simultaneously of a transport need that results in faster, more � exible responses while containing costs.

Technology in actionBy conducting research and negotiating pricing ahead of time, our sourcing tool allowed us to create a global network of more than 100 air ambulance providers that are on standby for a mission at the click of a button. On one screen, we can review all the variables, check for available empty legs and move quickly in getting the patient on his way. We can compare medical fees at the local hospital with repatriation costs, and determine if repatriation via a commercial � ight is a better option than air ambulance. This helps us pick the best providers – avoiding brokers – and minimises costs. And because we have already gone through the credentialing process and have established relationships with these air ambulance companies, Europ Assistance is given priority when demand is high, such as during a global crisis. This type of system also provides e� ciency for the air ambulance companies. Once we select the company with the bid that most closely matches our needs, they are immediately noti� ed so they can move quickly. In addition, those that weren’t selected are automatically alerted so they know that plane is open for another transport.For insurance organisations and other customers of assistance companies, a networked negotiation

Negotiating fair and efficient contracts before the air ambulance is actually needed is a plus for both the assistance company and air ambulance provider

The art of negotiation



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system also provides cost containment. Current and prospective customers often express distrust and frustration with bills they receive from assistance companies that are exorbitant. This is usually due to providers raising rates at the time of emergency. With our source tool, air ambulance providers see the bene� t in being part of a global system and o� ering competitive contract pricing for the volume scale.Proactive contracting by assistance companies can save time and money for their organisations and

their customers, while also giving reputable air ambulance vendors a healthy business channel and stronger relationship with the assistance company.

A case in pointA great example of how networked sourcing can not only save money, but lives, is when it gave us the power to save an 18-year-old man su� ering from heart failure thousands of miles from home. The young man, on the heart transplant waiting list, fell

ill while travelling in Panama and needed to return to his home hospital in Canada – immediately – for life-saving treatment. It’s tough on a good day to � nd an open hospital bed in Canada, but the hospital knew him and made sure they had a bed available to him as soon as we could get him back home. But we had to � nd an air ambulance that could have him on his way to Canada in the next few hours. Within 30 minutes of issuing a request through our system, we received 11 transport quotes. Two hours later, the patient was � ying home for

emergency treatment with his personal physician.Negotiating the best price for a medical evacuation is a key part of running a successful assistance company, but it’s also important to spend time researching the most reputable and safe vendors to provide the service. Doing so takes much time and e� ort. The time to do it is before it’s needed, so you as an insurance or assistance provider can make the most e� cient, safe and e� ective choice in seconds when peoples’ lives are at stake. n

Assistance companies are not just searching for the best price, but also for reputable providers with a proven safety record

Paige Schaffer is the vice-president of operations and chief service officer for Europ Assistance USA, providing best-in-class quality and service for customers and demonstrating unrelenting commitment to EA USA’s clients. Schaffer’s departmental responsibilities include emergency travel assistance (including medical team operations), health and travel claims management, identity theft resolution services, concierge services and training. She is a member of the International Customer Management Institute, US Travel Insurance Association and Association of Corporate Travel Executives.

Author



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Every year, the cost of delivering international private medical insurance (IPMI) increases. Even in good economic times, rising costs were an

issue for buyers of insurance and their providers, but now we are living in more prudent times, the issue is becoming more acute.Fortunately, the emerging Asia Paci� c economies, with their stronger growth and lower cost of labour, continue to be a magnet for expatriates of all nationalities. This means the demand for high-quality IPMI remains buoyant as expatriates and internationally mobile people demand access to medical care, when and where it is needed.While it seems to some that insurers are quite happy about continuously rising costs, simply passing on increased cost to buyers through ever-increasing premiums, the opposite is true. Insurers are now putting signi� cant resources into cost containment. Premium in� ation runs the risk of pricing buyers out of the market, which is bad news for insurers who want to deliver top-quality cover at a reasonable cost. While demand in the Asia Paci� c remains strong, we are already seeing moves by some employers to pare down the level of cover they are prepared to o� er their expatriate employees as a means of managing the overall cost of the insurance.The big issue for insurers is keeping the cost of cover manageable, without compromising the quality of their product or the increasingly high levels of customer service that are required to deliver quality medical care throughout the world.

There isn’t a single reason for IPMI premium in� ation and insurers are looking closely at all areas of their operations to contain costs:• Claims costs are increasing, driven by ever more

research and development, improved procedures, increasing hospital and medication costs and greater life expectancy, not to mention the impact of issues such as obesity, excessive alcohol consumption and more stressful lifestyles.

• Insurers are also seeing an increase in the cost of fraud, which is ultimately re� ected in premiums. This isn’t just from members exaggerating the cost of treatment, but also from a number of medical providers who are overcharging for services or overtreating patients.

• At an operational level, insurers are experiencing cost pressures. These include the costs of business acquisition and remuneration for introducers, as well as the cost of delivering services worldwide. Insurers are commercial organisations and also need to factor in costs such as the funding of risk capital and the cost of prudent and e� ective reinsurance so that secure and appropriate cover can be guaranteed in the event of exceptional claims or even a global pandemic.

Managing claims costsInsurers have a duty to ensure that they are paying the most competitive possible price for medical treatment from medical providers, without compromising the quality of care for their members. Prices can vary widely, even within a single jurisdiction, dependent on the approach and business model adopted from the provider. Using carefully selected medical providers, based on quality of care and their record for good clinical outcomes, enables insurance providers to deliver a more cost-e� ective service to their members. Of course, if a client wants cover that gives them access to a hospital that provides comfort more akin to a � ve-star hotel than a hospital, they should expect to pay more for their cover; the key is that they should know what their cover entitles them to, rather than assume the insurer will pay irrespective of cost.It’s also worth noting that across the Asia Paci� c region, the most expensive is not necessarily the best; some expensive Western-style hospitals have a stranglehold on advertising and marketing budgets – but their prices are high and their clinical outcomes are not always the best. Indeed, there are examples of poor quality outcomes from very expensive medical facilities. For the insurer, the key to managing cost is to build a real understanding of which hospitals and clinics deliver the most cost-e� ective, high-quality outcomes and to point members in their direction. Any insurer that aspires to really understand the local healthcare market needs a network of o� ces across the Asia Paci� c, regional and country managers on the ground and strong relationships with brokers plugged into their local markets.Managing claims cost is not just about knowing the best local provider – insurers also manage costs by negotiating agreed rates with healthcare providers. Clearly in a global business with hundreds and thousands of medical providers, it is not possible for an insurer to reach pricing agreements with every one – but in each region, there will be one or two major hospitals and hospitals that are

KEEPINGA LID ON ITSteve Conway describes how healthcare developments in the Asia Pacific region have led to cost increases, which in turn have resulted in a need for cost containment

the demand for high-quality IPMI remains buoyant as expatriates and internationally mobile people demand access to medical care, when and where it is needed



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frequently used by expatriates, so set prices can be agreed with certain key providers. The hospital network approach is particularly e� ective for large corporate group schemes, where the volume of members using a single hospital can enable the insurer to negotiate highly competitive rates for treatment.Education of clients has an important role to play in cost containment too. It is important that insurers communicate clearly with their members, so that they know exactly what bene� ts the cover entitles them to and which high-quality providers are available. Premiums for larger groups purchasing IPMI are usually directly linked to an employer’s claims record, and a poor claims record can mean high and potentially escalating premiums, so employers can contribute to reducing costs by eliminating unnecessary or frivolous claims by their sta� .Every employer will have its own approach to managing the medical claims process. The key is not to stop sta� making a claim when it is necessary, but to ensure that only necessary treatments and bene� ts are utilised at reasonable costs.

Employers should be aware that in many countries, medical facilities are highly commercial operations – they make more money if they can treat an employee as an inpatient rather than a day patient, and they can also make more money by performing several extra tests, where one would su� ce.It is, of course, a tricky balance for employers – they do not want to appear mean – or to give the impression that they are putting money before their employees’ healthcare. However, imbuing a culture of cost containment and keeping an open mind to the potential of overtreatment by some medical providers will work wonders for managing costs.

Reducing fraudSadly, a proportion of the cost of rising premiums is caused by fraudulent claims made by a handful of individuals and medical providers. The cost of fraud impacts every single member of an IPMI plan and insurers are taking increasingly tough action to stamp it out. Indeed, most IPMI providers in the Asia Paci� c region are members of the Health Insurance Counter Fraud Group and are working together to combat fraudulent claims.Frauds by individual members of schemes vary, but include: failing to disclose previous medical history, claiming for treatment in respect of a pre-existing condition during a moratorium period, claiming for treatments or services not provided, or using somebody else’s insurance to obtain treatments or services. Insurers also see incidences of invoices altered by members, often crudely, to in� ate the cost of a claim.Insurers are also alert to the dubious practices of a limited number of providers. These include billing for treatments that have not

actually been performed, falsifying diagnosis or conducting unnecessary treatments or procedures. Another underhand approach is to bill each stage of a single procedure separately in order to maximise revenue, or billing for a more complex version of the treatment or service than was actually provided. There have even been some cases of clinics billing for the same procedure more than once.One of the best ways to reduce overcharging by healthcare providers is to educate members about checking their bills carefully. It is quite common for hospitals to present a schedule to members at the end of a treatment period and to ask them to sign and con� rm that the treatments

have been received. Unsurprisingly, most members take the schedule at face value – whereas asking a few questions can often reveal mistakes – or on occasions deliberate misrepresentation.Insurers are also working hard to reduce the incidence of fraud by introducing strict controls to deter, prevent, detect and investigate fraud, as well as recovering payments whenever possible. Insurers are also reporting perpetrators to the appropriate authorities and bringing those responsible to justice whenever they have su� cient evidence of deliberate fraud.Top quality IPMI provides essential protection to expatriates and internationally mobile people. Without e� ective cover, they and their families would be exposed to the risk of being unable to access medical treatment when needed. Insurers are acutely aware of the importance of delivering a cost-e� ective, high-quality product and are increasingly focussing their resources on cost containment in order to manage and contain increases in the cost of premiums. n

Steven Conway is currently regional manager for Asia at InterGlobal, a UK FSA-regulated high-net-worth medical insurance provider. Overseeing operations in China, Singapore, Hong Kong, Thailand, Indonesia and Vietnam, he has ultimate responsibility for developing individual and group medical insurance products to be sold through a variety of lead partners and sales channels.

Author

Using carefully selected medical providers, based on quality of care and their record for good clinical outcomes, enables insurance providers to deliver a more cost-effective service to their members



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On the winning team

ITIJ recently caught up with Magdi Riad, president of SelectCare Worldwide, to talk about Canadian bed shortages, pricing transparency, Corvettes and a whole lot more

Let’s start with a bit of background information … where were you born, where did you study, and where do you live now?I was born in Cairo, Egypt. I joined the Civil Aviation Training Institute, from where I graduated with a masters degree in avionics. I currently live in Toronto, Canada, with my lovely wife and two children.

How did you come to work in the cost containment industry, and how did you end up in the role you currently hold? Did your background as a travel agent help in terms of knowing the typical behaviour of tourists when they need help?I joined the travel insurance industry at the beginning of 1993. My � rst job was in the call centre of an assistance department, where I came across hospitals o� ering ‘prompt-pay discounts’. It occurred to me then that healthcare providers’ pricing in the US was somewhat � exible. In 1994, I became the claims manager and created a unit to negotiate hospital bills in return for favourable discounts. I visited a lot of US claims payers to understand how to e� ectively manage relationships and negotiations with hospitals and how this all � ts together in a large volume organisation. In 1997, I became vice-president of claims and continued to learn more about hospital pricing and the threshold or tolerance level of each hospital in giving discounts. I also came to understand the di� erence between a community hospital and a non-pro� t or for-pro� t hospital. In 2001, we created SelectCare and I became the president. My background as a travel agent helped tremendously in terms of o� ering a � rst-hand account of what challenges a tourist may anticipate during a trip abroad, as I was able to pinpoint the right service for the client when they needed it most. We created an infrastructure to service the client around the types of questions they would be asking and what type of service we would provide for them. This experience was de� nitely the guiding principle for setting up the assistance department.

Can you describe the ways in which SelectCare Worldwide has embraced the use of technology in order to support its efforts in cost containment? SelectCare was always on the lookout for suitable software to manage its claims and assistance operations. While there was a lot of good software on the market, none was comprehensive enough to manage and track all of our operations. After an exhaustive search, we came to the conclusion that we must build our own. In 2001, we created Risk Management System (RMS), our proprietary Internet-ready software. It is easy to learn, intuitive and � exible enough to suit every policy bene� t, and allows us to manage our assistance and case management activities. Through RMS, we are also able to track recorded assistance and

case management calls and claims inquiries. We are able to track hospital and physician invoices by line items, look up historical discounts and contact names at provider o� ces.We batch re-price invoices by the hour electronically (EDI) and the data is HIPPA and PEPIDA compliant. RMS also tracks reserves, and tracks recoveries from Canadian provincial plans through co-ordination of bene� ts and/or subrogation. Our RMS was also built to handle multiple underwriters and pay claims in multiple currencies. The SelectCare website is not only a marketing tool, but also has a provider search functionality,

where policyholders can search providers by geographical location and specialities. Our website also allows claimants to submit their claim electronically, which speeds up the claim turnaround time tremendously.

How does SelectCare Worldwide choose which hospitals will be in its PPO network? And how do you ensure quality care is provided by approved providers year after year?In the US, we review hospitals based on size, speciality or expertise and location. There are acute care hospitals, which we must have – some of them are optional because of location, while others are a must. Hospitals in sunny destinations are our � rst priority and we must have good knowledge of their billing practices and, in some cases, signed contracts. We hold signed contracts with most reputable sunny destination hospitals while using PPO networks and/or no contracts with others.Having a contract with every hospital is not the best solution when it comes to cost containment; a contract is a binding document that sometimes, and with the wrong hospital administration, may work against the payer and cost much more than the real cost of treatment. So, there are many factors and variables in contracting with hospitals but, at the end of the day, it’s their rates and how much they will be charging and accepting as a � nal settlement that matters. On an international level, quality care is always a concern. We visit hospitals around the world and evaluate their expertise and capabilities and, once they pass the test, we include them in our network. Because we manage in excess of 1.5 million travellers with di� erent policy types and claims noti� cation requirements, we are unable to always control where individuals may seek

Consumer-driven care is the key to making transparent pricing work



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medical treatment. In these situations, our sta� physicians are involved in every case reported and as soon as abuse, negligence or any sign of malpractice is apparent, we move the patient to a nearby hospital where adequate medical treatment is available. ‘Nearby’ could be thousands of miles away and reachable by way of ground or air ambulance; it all depends on where the patient is.

As a subsidiary of the Co-operators Life Insurance Company, one of Canada’s largest multi-product insurers, how does SelectCare Worldwide take advantage of being part of a larger group?SelectCare Worldwide is part of a large group indeed, and we take full advantage. Some of the bene� ts include IT infrastructure and support, litigation and legal opinions, access to a broad distribution network, product and underwriting expertise, and marketing functions and support; and it broadens our expertise and opportunities. We are also members of their senior management team and regularly meet to discuss issues facing our organisation and the industry as a whole.

Furthermore, we are part of The Co-operators Group of companies, which includes seven reputable insurers and provides tremendous � nancial stability to SelectCare Worldwide.

The issue of bed shortages in Canadian hospitals has been widely reported. Has your company seen evidence of this, and if so, how do you see the situation developing? Will it only get worse as government health systems are ever-more strained?Yes, of course – we’re Canadian. We live and breathe our healthcare system and we know the wait times when it comes to special procedures. We also know that bed shortages in Canada are a troubling issue. Through our membership of the Travel Health Insurance Association (THIA), e� orts are currently underway to discuss this issue with the Ontario Health Insurance Plan (OHIP). Ontario Premier Dalton McGuinty has expressed concern about this topic and a proposal has been created to highlight some of the areas that need to be addressed. I don’t think this issue

will be resolved overnight – it’s ongoing, but our government is working with the travel health industry to actively � nd solutions.

There has been an increased call for pricing transparency in the US with regards to what hospitals charge, and what they receive in the way of payment. Is this a welcome move? The concept of pricing transparency is a hot topic these days. I personally � nd it to be a useful � rst step. It would be nice to see hospitals competing for business once again. Our main concern is and will always be how consumers are completely disconnected from the cost of their medical bills. Because of our role as payers, we have kept the consumer unaware of the real cost of healthcare. We have taken charge of directing their care and absorbing their cost. Consumer-driven care is the key to making transparent pricing work. This is only achievable through engaging individuals to be more responsible in managing their health and purchasing healthcare services. The combination of high deductibles and co-insurance gives individuals greater control over the � ow of their health spending dollars. It will de� nitely take time for the average consumer to understand and be able to navigate a hospital’s Charge Description Master (CDM). A standard CDM may contain more than 10,640 item codes. Add CPT®/HCPCS codes to the equation and the consumer will have a really tough time � guring out how much a treatment will cost.In general, in an emergency situation, prices for health services do not matter to consumers. When a complex, life-threatening event confronts them, consumers are not prone to ‘shop’ for prices. Comparisons between the quality of care based on demonstrated outcomes or word-of-mouth endorsement is most likely to win over price

comparison. Pricing information that matters most to consumers appears to be for services that are routine – o� ce visits, tests, elective surgeries, medications, and so on. From a payer point of view, this is something we may bene� t from in the future. SelectCare and most prudent claims administrators/payers have created databases that track pricing by providers. It would be nice to compare and track hospital CDMs and properly calculate hospital in� ation

rates. It will also make our jobs much easier comparing one CDM to another and to negotiate better agreements.

If you could be in any other industry, what would that be, and why?Well, I’ve only been in two industries. While I enjoy working in the insurance industry, my second choice would be travel. Travel is a lot of fun, and I enjoy networking and meeting people.

What are you most proud of – both personally and professionally?Personally, I’m most proud of my wife and two children and my people. Professionally, SelectCare Worldwide has achieved much. We are a relatively new organisation that has built its foundation on the experience and dedication of its people. And we are very proud of our results. As a claims payer and an assistance company, we are very proud of what we bring back to the insurer and the people we serve.

What is your guiding philosophy and what motivates you?I always thought that realising your dream is a journey that you cannot complete by constantly looking back. In other words, you have to always push forward and don’t let mistakes stop you; acknowledge them, count them as experience and move on. I also always plan where I’m heading, so I’m careful where I position my � rst step.Success for me is a great motivator. It is a sense of self accomplishment. At SelectCare Worldwide, we have hundreds, if not thousands, of success stories that we pride ourselves on. Again, who would want to be on the losing team?

What do you do in your spare time?In my spare time, I enjoy restoring cars. It is another way for self-accomplishment. I’m currently restoring a 1981 Corvette.

If you were hosting a dream dinner party, what would you eat and who would you invite?If I were hosting a dinner party, I would serve beef tenderloin with all the trimmings. I would invite: Julia Child to do the cooking, Bruce Willis to share some great Hollywood stories, and the comedian Russell Peters to make fun of us all!

Where was the last place you went on vacation, and where would you like to visit next?I went on vacation this past summer to a cottage on Rice Lake with my family. We had a wonderful time. For my next trip, I would like to go home to Egypt, but will have to wait until it is safe so I can enjoy my friends one more time. n

It would be nice to compare and track hospital CDMs and properly calculate hospital inflation rates

always push forward and don’t let mistakes stop you

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