MyHealthGuide Newsletter
News for the Self-Funded Community

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General & Company News
People News Market Trends, Studies, Books & Opinions Legislative News Medical News Recurring Resources Upcoming Conferences

Job News

Clicking a job listing below will open a webpage with job summary, details and links to additional information (when available). Initial publish date is shown right of listing. Listings are generally published for 1 month.  This new format was prompted the Newsletter becoming so large that some filters and email systems blocked the delivery.   Editorial Notes, Disclaimers & Disclosures

General & Company News

Verikai Introduces Marketplace to Simplify the Placement of Group Health Insurance for MGUs, Underwriters and Brokers

MyHealthGuide Source: Verikai, 7/12/2021

SAN FRANCISCO - Insurance technology startup Verikai has updated their user interface and with it launched their new product: Marketplace. Verikai uses machine learning models to give insurance providers a deeper view of risk, using extensive clinical and behavioral data. Now, with the addition of the Marketplace, brokers will be able to run group reports through Verikai's established system and immediately get matched with underwriters who are willing to write the group.

Most insurance brokers face the long-standing problem of finding the most competitive policies for their clients while being confined to their established network of carriers. Verikai's Marketplace takes the stress away, opening doors to new carrier contacts and avoiding the need for previous claims data or individual health questionnaires. Brokers and carriers can communicate entirely through the Marketplace platform, from initial report submission to RFP approvals, and finally to quote binding; all in a fraction of the time.

"We are so excited to join Verikai's Marketplace and see how the platform will elevate our business," said Michael Juergens from Leavitt Group. "We started using Verikai recently and the results speak for themselves. Verikai's risk insights hold substantial weight during rate negotiations - sometimes resulting in double-digit decreases. And with the Marketplace, binding competitive rates should be easy, because the carriers see the same reports we do, and they already understand the precision of Verikai's risk predictions. There's really nothing else like this on the market, and we can't wait to dive in."

Verikai's President and CRO, Jeff Chen, said, "We're striving to improve health insurance for all parties involved, and in working towards that goal, we created a tool that will help our customers better serve employers to meet their insurance needs. While updating our user interface, we thought could a single UI built on our risk scores help both brokers and underwriters? Given the ACA has a marketplace for consumers to find individual insurance options, a similar solution could also exist for group health. It was during this time that the Marketplace was born. Nine months later, here we are launching the most exciting product in our company's history."

About Verikai

Founded in 2018, Verikai is an insurance technology company leveraging alternative data and machine learning to change the way the industry views risk. Our well-established database of more than 1.3 trillion data points includes over 5,000 behavior attributes for 250+ million people in the United States and provides deep insight to these individuals' true health risks. With this data, Verikai generates risk reports in real-time with only a census. This greater insight helps insurance companies increase new business, reduce losses and improve efficiency in the underwriting process - and ultimately, provide consumers and businesses with greater access to a broader range of insurance products.  Contact Ellie Newby, Marketing Manager, at and visit

Fortified Health Security Releases 2021 Mid-Year Horizon Report

MyHealthGuide Source: Fortified Health Security, 7/13/2021 

Findings detail an increase in cybersecurity threats throughout first half of 2021; offers actionable guidance for combatting malicious activity, while building awareness of healthcare’s cybersecurity landscape

FRANKLIN, TN – Fortified Health Security, Healthcare's Cybersecurity Partner®, today released the 2021 Mid-Year Horizon Report. The report details findings that illustrate how healthcare providers, health plans and business associates are being affected by cybersecurity threats from bad actors in the first half of 2021 and what security measures healthcare organizations should implement to combat these high-profile threats.

The report leverages a comprehensive cross-section of information, expertise and statistical analysis to highlight industry-wide trends, insights and predictions. Horizon Reports have been published by Fortified Health Security since 2017 and are designed to help healthcare stakeholders navigate the exceedingly complex cybersecurity landscape by sharing best practices and actionable guidance.

Significant findings from the 2021 Mid-Year Horizon Report include:
  • The number of breaches reported to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) in the first six months of 2021 increased by 27% over the same period in 2020.
  • The total number of affected individuals skyrocketed more than 185%, from 8 million individuals in the first six months of 2020 to 22.8 million affected individuals in the first six months of 2021.
  • Healthcare providers continue to account for the most breaches, 73% of the total, with health plans accounting for 16% and business associates 11%.
  • Malicious attacks were the No. 1 cause of breaches for the fifth consecutive year, and for three years running, malicious attacks accounted for 73% of all breaches.
“Now as the healthcare industry gets some breathing room from the pandemic, another one is surging –cyber attacks,” said Dan L. Dodson, CEO of Fortified Health Security. “The attacks on our nation’s critical infrastructures which includes our hospital systems, has resulted in government agencies showing a renewed focus on cybersecurity. This has helped move cybersecurity to the forefront of many boardroom discussions. We, as healthcare leaders, must seize this opportunity to educate and inform stakeholders on the current cybersecurity threat landscape and the actions needed to combat these attacks.”

The pandemic forced many healthcare organizations, along with other industry segments, to establish remote work environments for non-patient-facing workers, leading employees to transform bedrooms and kitchens into home-office spaces. As a result, the prevalence of a remote workforce expanded the attack surface that cybersecurity teams in virtually all industries had to protect, as private records and data moved outside their facilities. According to the report:
  • SolarWinds alone potentially affected 18,000 companies, including 400 of the Fortune 500 and the U.S. Department of Homeland Security.
  • Blackbaud’s breach affected an estimated 100 organizations, hitting healthcare particularly hard, resulting in nearly two dozen lawsuits.
  • Cybercrime is expected to inflict $6 trillion in global damages this year, a figure predicted to climb to $10.5 trillion by 2025.
  • More than nine in ten U.S. companies have suffered a breach in the past year due to a supply chain weakness.
Earlier this year, Fortified Health Security released the 2021 Horizon Report – detailing findings that illustrate how, as healthcare organizations continue to respond to the pandemic, cybercriminals have continued to persist in their attacks on providers, health plans and business associates compromising sensitive patient data, while impacting the delivery of care to patients.

Fortified Health Security’s 2021 Mid-Year Horizon Report builds on that guidance, while aiming to predict the short-term future of cybersecurity in healthcare. The full report is available for download here.

About Fortified Health Security

Fortified Health Security is Healthcare's Cybersecurity Partner® – protecting patient data and reducing risk throughout the healthcare ecosystem. As a managed security service provider, Fortified works alongside healthcare organizations to build tailored programs designed to leverage their prior security investments and current processes while implementing new solutions that reduce risk and improve their security posture over time. Fortified’s high-touch engagements and customized recommendations maximize the value of investments and result in actionable information to help reduce the risk of cyber events. The company is 100% committed to creating a stronger healthcare landscape that benefits more clients, protects more patient data, and reduces risk.  Contact, (615) 600-4002 and visit

The Phia Group Announces Recorded Webinar: Surprise, surprise! Analyzing the No Surprises Act Part Deux

MyHealthGuide Source: The Phia Group, 7/16/2021

Recorded Webinar: Surprise, surprise! Analyzing the No Surprises Act Part Deux

Description: In the afternoon hours of July 1st, 2021, several U.S. departments released some much-anticipated surprise billing regulations, meant to implement the No Surprises Act. When that act was first outlined in the Consolidated Appropriations Act of 2021, The Phia Group was there to provide you with a detailed assessment of the rules. Now, join The Phia Group as they once again dive into the world of surprise bills and dissect this important law. From discussing what we know, to outlining what is yet to come, anyone who will be impacted by this law (and - spoiler alert - that includes you), must listen to this recorded webinar. Recording Link.   

About The Phia Group

The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, Contact Garrick Hunt at , 781-535-5644 and visit


People News

Ray Cox, Stop-loss Underwriting Pioneer, Passes

MyHealthGuide Source: DignityMemorial, 7/12/2021

Raybon (Ray) E. Cox (83) was called home to the Lord July 12, 2021. He passed in his home on St Pete Beach, FL. He was born October 1, 1937 in Danville, Kentucky to the late Robert & Patricia (Stapp) Cox. He resided in both Greenwood, Indiana and St. Pete Beach, Florida.

Ray Cox
Raybon Edward Cox
Founder of Cox Insurance Group

Ray graduated from Greenwood (Indiana) Community High School. After graduating high school, Ray enlisted in the United States Navy. He was a “career” military man, serving 21 years all around the world including Vietnam in 1967-1968. He achieved the distinguished rank of Master Chief Petty Officer. Ray got to pick his last Post and picked San Diego California based on its beauty and climate.

After serving, returned to Greenwood Indiana and entered the insurance industry and ultimately started Cox Insurance Group (CIG), a medical stop loss company in 1981. Ray owned and operated CIG until selling it in 1993.

Upon selling CIG, he spent the last 30 years pursuing his passions of golf, traveling and car collecting. Ray had a passion for both classic and new cars. He continued to purchase cars even while under hospice care over the past 9 months, buying his last car (a 1957 Ford Thunderbird) just 3 weeks prior to his passing. In his declining condition, he continued to speak about taking his “new” 57 TBird out on the road. That never happened, but it wasn’t for lack of interest.

A Celebration of Life will be held at Isla Del Sol Golf & Country Club Monday July 19th at 11:00. An additional Celebration of Life will be held in Greenwood on a date tbd.

Fond memories and expressions of sympathy may be shared at for the Cox family.

Tokio Marine HCC – Stop Loss Group (TMHCC) Promotes Charlie Carlson, David Grider and Tom Matchinksy

MyHealthGuide Source: Tokio Marine HCC, 7/16/2021

Tokio Marine HCC – Stop Loss Group (TMHCC) is pleased to announce key promotions for the executive management team effective July 15, 2021. For more than 45 years, TMHCC has paved the way for medical stop loss and organ transplant coverage, and the promotion of these experienced individuals will allow us to continue our growth.

Charlie Carlson has been promoted to Chief Underwriting Officer. Since joining our team in 2014, Charlie has served as the Senior Vice President of the Northwest Region and has been influential in the leadership and expansion of this region. His industry knowledge and vast experience will help continue TMHCC’s growth as a leader in the medical stop loss industry and help us move into the future.

David Grider has been promoted to Chief Marketing Officer for TMHCC – Stop Loss Group. David has worked for TMHCC for 27 years, most recently serving as Senior Vice President of Marketing and Sales. David has been instrumental to the growth of TMHCC’s Corporate Marketing Department and will continue to lead the communication of TMHCC’s products and services in the self-insured industry.

Tom Matchinksy has been promoted to Senior Vice President of the Northwest Region. Tom has worked for TMHCC since 2014 and previously served as the Vice president of Underwriting for this region. He has been a significant contributor to TMHCC’s growth with stellar results, and this transition will help continue that success.

Jay Ritchie, President and CEO of TMHCC’s Stop Loss Group said, “We are excited and confident that these experienced leaders will continue to be major contributors to our success going forward. Please join us in congratulating David, Charlie, and Tom on their new roles, we thank them for their hard work and dedication to TMHCC."

About Tokio Marine HCC (TMHCC)

TMHCC is a leading provider of medical stop loss insurance provided through brokers, consultants and third-party administrators. By listening to the demands of the market, we have developed exceptional products, unparalleled resources and value-added services that set us apart in the industry. Visit our website to learn more about our innovative stop loss, Taft-Hartley, captive and organ transplant solutions.  Visit

Symetra Names Daniel Palermino SVP, Benefits Distribution and Field Service

MyHealthGuide Source: Symetra Life Insurance Company, 7/14/2021

BELLEVUE, WA — Symetra Life Insurance Company announced the appointment of Daniel Palermino as senior vice president, Benefits Distribution and Field Service. In this new role, Mr. Palermino will have responsibility for all aspects of sales and field service activities across the Benefits Division’s product lines, including group life and disability insurance, voluntary benefits and stop loss. He reports to Harry Monti, executive vice president, Benefits Division, and will be based in Massachusetts.

Dan Palermino
Dan Palermino
SVP, Benefits Distribution and Field Service

Dan “I am excited to have Dan join our team as we continue to expand Symetra’s presence in the group benefits marketplace,” said Harry Monti. “Dan’s appointment is an important step forward in supporting our growth objectives, while continuing to progress toward a vision of maximizing ways in which we can create deeper customer relationships and use our full product suite to create value for them. Whether that be through our support of an employer’s medical plan with our stop loss offerings, covering consumers’ health-related costs, assisting families that have lost a loved one, or providing financial benefits after a disability — or through a combination of our products — we have the opportunity to help employers be successful and to make a real difference in their employees’ lives.”

Mr. Palermino brings an extensive employee benefits background to his new role. He joins Symetra from Voya Financial, where he was vice president, Employee Benefits Sales, leading their national employee benefits sales organization. Prior to Voya, he was vice president and head of Employee Benefits Distribution at AXA Employee Benefits, where he led a multi-channel distribution and field service organization. He previously served in leadership roles at several other insurers, including as head of sales for AIG’s core and voluntary benefits.

Mr. Palermino received a bachelor’s degree in political science and economics from the University of New Hampshire.

About Symetra

Symetra Life Insurance Company is a subsidiary of Symetra Financial Corporation, a diversified financial services company based in Bellevue, Washington. In business since 1957, Symetra provides employee benefits, annuities and life insurance through a national network of benefit consultants, financial institutions, and independent financial professionals and insurance producers. Visit

Employers Health Network Founder and CEO, Spike Dietrich, assumes new role as Blake Allison promoted to Chief Executive Officer

MyHealthGuide Source: Employers Health Network (EHN) , 7/16/2021

Grapevine, TX – Employers Health Network (EHN) announced that Blake Allison, executive vice president, will become chief executive officer effective July 1, 2021. Founder and CEO, Orlo “Spike” Dietrich, will assume a new role as founder, strategic advisor, and remain a board member of EHNexus (EHN’s parent company), while continuing to take part in the strategic direction of EHN. With this transition, Allison brings almost 20 years of experience in the healthcare and provider system industries.

“Having been involved with starting and managing healthcare companies for almost 40 years, I will say with the utmost confidence that Blake is one of the most exceptional executives I have known, with deep experience leading provider systems. EHN is in very good hands,” said Spike Dietrich.

Dietrich launched EHN in 2015 alongside Russell Burks, co-founder, chief financial officer, and board member, with the firm conviction to fulfill a critical need in the market by bringing self-funded employers and medical providers together as true partners. Structured around a fully transparent infrastructure, Dietrich and Burks aimed to form these partnerships as complete benefit product solutions that focus on the highest quality care and offer a benefit structure that employees and their families can rely on with the highest degree of certainty. In 2021, EHN experienced rapid growth with movement into several new markets, driven by both the EHN health system and their employer partners.

Russell Burks noted, ”Blake has excellent executive leadership skills and has facilitated true integration with our provider partners, including participation in EHN’s care management programs. He brings a level of energy and focus that is infectious. We are delighted that he accepted the CEO position.”

Blake Allison stated, “EHN was founded on the mission of bringing high performing healthcare providers and employers closer together across a transparent infrastructure to drive innovation in support of high value healthcare. The company continues on that mission today, and I am humbled by the opportunity to continue to move our company forward towards new growth opportunities. EHN has developed a team of industry leaders across all areas of healthcare and I am grateful to Spike, Russ, and the entire board, as well as our team, for the true privilege to serve as CEO. We are excited about our future and look forward to impacting healthcare in the local community in a positive way.”

Prior to joining EHN in 2020, Allison served as chief executive officer for Southeastern Health Partners in Greenville, South Carolina and as chief operating officer at Baylor Scott & White Quality Alliance in the Dallas/Fort Worth, Texas area.

About EHN

Employers Health Network (EHN) provides comprehensive healthcare plans, which allow employers to provide exceptional quality healthcare benefits at the lowest possible cost. Our plans connect employees directly with the best quality healthcare providers and our fully transparent pricing allows customers to see, understand and control their healthcare benefit spending. Contact Victoria Walters, Manager - Marketing & Business Development, at and visit

HealthComp Appoints Reference-based Pricing Thought Leader John Powers to Vice President of Sales

MyHealthGuide Source: HealthComp, 7/12/2021

FRESNO, CA – HealthComp, the largest independent health benefits administrator in the country, today announced the appointment of John Powers to the position of Vice President of Sales. In this role, Powers will drive growth among brokers and their mid- to large-sized employer groups at both regional and national levels.

John Powers
John Powers
Vice President of Sales

“We’re thrilled to have John join our sales team,” said Tom Martel, CGO of HealthComp. “From his tenure in the industry, he’s built extensive relationships with brokers, benefit advisers, and employer groups across the country. With this expertise, he’ll be able to help us broaden our reach nationwide, while deepening our market penetration in key geographic areas. His experience in meeting the needs of mid- to large-sized employer groups also comes at an opportune time when we are exponentially growing in this position.”

“For the past 15 years, I had the privilege of working alongside HealthComp as a business partner,” said John Powers. “In that capacity, I worked with many TPAs, and HealthComp stood out as the market leader. Now, I’m privileged to join the team and be part of the company’s mission to deliver outstanding value. Our low cost trend of 2.4% versus the industry average of 5.8% demonstrates an ability to truly impact the healthcare cost curve. In addition, our Net Promoter Score of 80 versus the industry average of 12 underscores the superior experience we can provide plan members.”

Powers is an expert on reference-based pricing (RBP), having worked on RBP plans for over a decade. He has an in-depth understanding of the factors that contribute to RBP success, including member education and outreach, change management, and direct contracting. And because HealthComp has Centers of Excellence for both RBP and PPO plan administration, he has the flexibility to offer clients more plan options.

“I’m excited to introduce brokers and their clients to HealthComp’s RBP Center of Excellence. And while I’m passionate about RBP, I understand that the best health plan is about balance. Toward that end, I now have the advantage of being able to offer clients the industry’s most comprehensive RBP program, as well as the best PPO networks,” noted Powers.

And as a recognized expert on RBP, Powers is in tune with key trends making it an opportune time to consider RBP. “With the economy reopening after COVID-19, there’s increased competition for human capital,” he added. “RBP offers a win-win for companies and prospective employees. For example, HR departments can still offer quality health benefits to attract candidates, while CEOs and CFOs embrace RBP’s ability to rein in healthcare spending.”

“RBP has certainly evolved,” noted Powers. “Early on, it was viewed as a disruptor, and groups who were early adopters were seen as taking a risk. Today, RBP has moved into a more mature phase, where an early majority look to RBP experts, like HealthComp, to show them the ropes.”

Powers’ previous roles include executive vice president of sales and marketing at AMPS. In this position, he provided leadership in healthcare cost management services to self-funded employer groups, third-party administrators, health plans, HMOs, and insurance companies. Prior to that, he served as vice president of strategic partnerships and network development at inVentiv Medical Management, where he led technology-enabled medical management and cost containment, all while ensuring quality patient outcomes.

About HealthComp

HealthComp, a New Mountain Capital company, is the nation's largest independent health plan administrator for self-funded employer groups. Our solution brings together concierge-level service, best-in-class operations, powerful analytics and expert medical cost management and integrates seamlessly with any benefits ecosystem. The result is an industry-leading experience that delivers better clinical outcomes for our members and higher savings for our book of business. HealthComp Holdings is the parent company of HealthComp (Fresno, CA), BAS Health (Homewood, IL), Benefit Assistance Company (BAC) (Ripley, WV) and Significa Benefits Services (Lancaster, PA).  Visit

Vālenz® Appoints Brian Fabbro as Vice President, Business Development

MyHealthGuide Source: Vālenz®, 7/19/2021

PHOENIX, AZ — Vālenz®, a leading innovator for a data-driven ecosystem of solutions that reduces medical claim costs and promotes quality healthcare, today announced the appointment of Brian Fabbro as Vice President, Business Development. With more than 14 years’ experience in sales and account management in the health industry, Fabbro is highly skilled in business and market development and client services. “With a tremendous background in developing strategic partnerships and delivering innovative medical cost containment solutions to the self-insured employer community, Brian is very well positioned for this key role in accelerating growth for the company,” said Nathan Nelson, Senior Vice President, Growth. “He offers a winning combination of creating and executing enterprise initiatives that exceed sales targets and take the company forward. We are excited to welcome him to the Valenz team.”

Fabbro brings leadership experience in the healthcare and insurance industries and specializes in consultative benefit planning, cost management, and tailoring high-impact self-funded solutions to client needs. He excels in managing distribution channels, cultivating business partnerships, and developing new territories and revenue streams.

“It’s truly an honor to join a company that is leading the way toward lowering costs holistically and improving health outcomes through its unique ecosystem of data-driven services,” Fabbro said. “Valenz is an excellent fit for my skills, and I look forward to supporting business growth that aligns with better, more cost-effective healthcare.”

Before joining Valenz, Fabbro most recently served as Sales Director for a tech-enabled third-party  administrator in St. Louis, Mo. He also has held key positions at other companies including Benefit Planning Consultants Inc., Cigna, and Washington National Insurance Company. Fabbro is a graduate of Butler University in Indianapolis, Ind.

About Valenz

Valenz enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz offers transparency through data to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate employees to optimal care solutions for substantial cost savings and improved health outcomes. Visit Valenz is backed by Great Point Partners.

AMPS Broadens Taft Hartley Segment with Esther Marcial as VP, Enterprise Sales and Labor Markets

ATLANTA, July 13, 2021 – Advanced Medical Pricing Solutions (AMPS), a pioneer in healthcare cost containment, welcomes Esther Marcial to join its growing business development team. In her new role as vice president, enterprise sales and labor markets, Marcial will expand AMPS’ Taft Hartley division to deliver effective long-term cost containment solutions to Taft Hartley Funds across the U.S.

Esther Marcial
Esther Marcial
Vice President, Enterprise Sales and Labor Markets

Marcial brings to bear more than 25 years of achievements in employee benefits. She comes to AMPS after serving as vice president – public sector, labor and trust with UnitedHealthcare, where she managed a diverse book of public sector, labor and non-labor trusts and led sales strategies in California public sector and labor markets.

“Esther brings proven career expertise to AMPS, and we are confident that her leadership will support our continued growth and expansion into Taft Hartley Funds nationwide,” said Lawrence Thompson, chief revenue and strategy officer of AMPS.

Marcial will deliver key offerings to Taft Hartley Funds, including AMPS’ medical bill review, reference-based pricing, stop loss, and pharmacy solutions.

“AMPS continues to invest in the Taft Hartley market to serve those clients and help them save thousands of dollars per member, year over year,” noted Kirk Fallbacher, AMPS president and CEO. “Our cost containment programs are designed to help these unique organizations save healthcare costs and increase member satisfaction, while also supporting the needs of the unions and Fund trustees.”

About Advanced Medical Pricing Solutions (AMPS)

Advanced Medical Pricing Solutions (AMPS) provides market leading healthcare cost containment solutions serving self-funded employers, brokers, TPAs, health systems, health plans, Taft Hartley Funds, and reinsurers. AMPS mission is to help clients attain their goals of reducing medical and pharmacy costs while keeping members satisfied with quality healthcare benefits. AMPS leverages its 15+ years of experience and data in auditing and pricing medical claims to deliver "fair for all" pricing. AMPS offers detailed analytics and transparency to provide clients with insights based on plan performance. Contact Tara Rowland at and visit


Crum & Forster Promotes Justin Hansen to National Sales Director

MyHealthGuide Source: Crum & Forster, 7/12/2021

Crum & Forster announces that Justin Hansen has been promoted to National Sales Director. Recently celebrating two years with C&F, Justin began his career with A&H as the South East Regional Sales Manager for the Direct Employer Stop Loss Unit.

Justin Hanson
Justin Hansen
National Sales Director
Crum & Forster

Designed to facilitate scale in this product line, the position challenged Justin to establish and grow relationships with brokers and TPAs in the southern belt. In his short time with the company, he has succeeded in not only breaking new ground, but in building this territory into an estimated $10M production funnel for A&H.

Justin’s driving success is no doubt a product of his more than 20 years in the employee benefits/worksite products insurance space and I am excited to see this success scale yet again as he tackles this opportunity at the national level. Justin will report directly to me and lead the sales team in executing on the full slate of DESL strategic growth initiatives.

About Crum & Forster

C&F and Crum & Forster are registered trademarks of United States Fire Insurance Company. Crum & Forster, which is part of Fairfax Financial Holdings Limited, is comprised of leading and well-established property and casualty business units. The insurance companies within Crum & Forster, rated A (Excellent) by A.M. Best Company, are: United States Fire Insurance Company, The North River Insurance Company, Crum and Forster Insurance Company, Crum & Forster Indemnity Company, Crum & Forster Specialty Insurance Company, Seneca Insurance Company, Inc., Seneca Specialty Insurance Company, First Mercury Insurance Company, and American Underwriters Insurance Company. Visit

Market Trends Studies, Books & Opinions

How claims data technology is becoming an expectation

MyHealthGuide Source: BenefitsPRO, 7/14/2021

BenefitsPRO Editor’s note: We recently chatted with Anne Brunson, VP of Service Operations at Maestro Health, about the future of claims data, technology and self-funding.

1. How can self-funded employers leverage their health plan data?
Anne Brunson: One of the benefits of moving to a self-funded model is having better access to claims data and the ability to pull its insights. With the help of an independent third-party administrator (TPA), employers have access to their claims and data around the services they’ve utilized, which helps the TPA and employer identify cost drivers, tailor the plan to their members’ needs and forecast what their claim spend will look like.

For example, if your data shows that you have a high percentage of avoidable ER visits, this indicates that members are going there instead of to a physician’s office or urgent care for primary and non-emergency care. With these insights, the employer could work with the TPA to work disincentives into the plan, like higher co-pays for unnecessary ER visits or member education materials about where to seek the right care at the right time, etc.

Utilization and claims data like this can help employers better understand their members’ needs, where they need to provide additional resources and how to tailor the plan to be as cost-effective and accessible as possible.

Companies who are fully-insured typically don’t have this level of visibility into their costs and employee needs, which is why this is a unique benefit of moving to a self-funded model.

2. How can employers who are considering going self-funded get access to their data? What if they can’t get access?

Anne Brunson: For a fully insured employer, the best bet is to work through their broker to obtain the information. While the insurer will probably not provide the claims data to analyze, they should be able to obtain specific reports, such as ER usage and high dollar claims, for example.

3. What are some of the key features of health care and claims analytics tools?

Anne Brunson: Just as companies expect sophisticated and well-rounded tools for their marketing and business efforts, employers want technology that allows teams to make important decisions about the health plan of the company. Some key features of these reporting tools include looking at cost drivers, plan utilization, and member needs/gaps in care and high-cost claim trends. Make sure the tool has the ability to drill down, as well as the ability to create cohorts within the participating population. And most importantly, make sure the employer and broker can access the reporting tool themselves. They may choose to let the TPA run the reports, but it is their data and they should have on-demand access to it. Due to the regulations around health care data and the complex nature of health claims, having tools that can pull out valuable insights with the correct reference points or pricing is crucial. This will help TPAs and employers design the benefits plan that fits their employee base and reduce unnecessary costs.

4. What types of programs can employers put in place?

Anne Brunson: Employers can work with their TPA to analyze data and pull valuable insights to address the cost drivers and health needs of their workforce. For example, programs that offer dashboards and easy-to-use tools are preferred for stakeholders to convert claims into unique visits, identify incomplete data and categorize providers to identify cost trends. TPAs are able to assist employers in pulling this data to make cost-saving or care management recommendations. With data insights readily accessible, employers can create more customized health plans, meet the clinical care needs of employees and drive down costs at the organization.

5. Why isn’t it standard practice to provide employers with their members’ claims history and data?

Anne Brunson: Companies that are fully-insured do not have the capabilities to see into past claims, trends and costs associated with regular claim outcomes, since the insurer does not provide the information. Larger insurance companies use the claims data in aggregate, and are not interested in it on a group by group basis. By moving to a self-funded model with the help of a TPA, employers are given access to their claims data and can truly see into how costs are being distributed.

About Maestro Health

Maestro Health is a tech-enabled TPA who can help employers navigate the system. Our self-funded benefits solution gives you the power to control your costs and make healthcare better for everyone involved. We’re helping employers regain control with our tech-enabled solutions and access to data.  Visit

Legislative News

Stop-loss insurance does not deem a self-funded plan as “insured” under ERISA

MyHealthGuide Source: Kantor & Kantor, 6/16/2021

Case: Hua v. Board of Trustees, No. 20-748 (MAS) (TJB), 2021 WL 2190906 (D.N.J. May 28, 2021) (Judge Michael A. Shipp).  Court's Opinion

Defendants offered self-funded medical benefits and maintained stop-loss insurance coverage as part of an employee benefit plan governed by ERISA. Stop-loss coverage was in force. 

The plaintiff was injured in an accident and filed a personal injury action against third parties.

Defendant Board of Trustees subsequently asserted an equitable lien by agreement against plaintiff’s potential tort recovery. Plaintiff sought declaratory judgment to bar the lien pursuant to state insurance regulations, arguing that the Fund was insured for preemption purposes because of the stop-loss coverage.

The court disagreed, citing Third Circuit precedent that explained that stop-loss insurance is designed to protect self-funded plans rather than individual participants, so plans purchasing stop loss insurance are not deemed “insured” under ERISA.

The court granted summary judgment to defendants, determining that the plan was self-funded and therefore state insurance regulations were preempted by ERISA and defendants’ lien was enforceable.

Stop-loss insurance does not pay participants’ benefit claims and may not even reimburse the plan sponsor or plan for all catastrophic claims. Therefore, stop-loss does not shift the risk at the individual level like traditional insurance.  Therefore, having stop-loss coverage does not jeopardize the ERISA exemption.

Medical News

Nonalcoholic Fatty Liver Disease (NALFD) Increases Mortality in Children and Young Adults Over the Long Term

MyHealthGuide Source: Laura Joszt, MA, 7/8/2021, AJMC

A long-term Swedish study found that nonalcoholic fatty liver disease (NALFD) significantly increased mortality in children and young adults, particularly due to cancer, cardiometabolic disease, and liver disease.

Children and young adults with nonalcoholic fatty liver disease (NALFD) have significantly higher mortality compared with the general population. According to the study published in Journal of Hepatology, the excess mortality was primarily from cancer, cardiometabolic disease, and liver disease.

Researchers evaluated a nationwide cohort of pediatric and young adult patients in Sweden with biopsy-confirmed NAFLD and compared them with matched general population controls to analyze overall and cause-specific mortality based on the presence and severity of NAFLD.

While there have been studies on NAFLD in adults, there is little known “about the long-term prognosis and histological correlates of survival” in children and young adults with NAFLD, the authors explained. They noted that 7.6% of the general pediatric population worldwide and more than 30% of children with obesity have NAFLD.

Children who are diagnosed with NAFLD may already have fibrosis, and a rapid progression to nonalcoholic steatohepatitis (NASH), a severe form of NAFLD.

Study findings
  • The study included 718 children and young adults with NAFLD. Among these individuals, 446 (62.1%) had simple steatosis and 272 (37.9%) had NASH. Less than half (44%) were diagnosed younger than age 18.
  • Compared with the control population (n = 3457), the patients with NAFLD were more likely to have cardiovascular disease (1.4% vs 6.8%), diabetes (0.3% vs 5.6%), and other metabolic comorbidities (0.5% vs 13.6%).
  • During the follow-up period (median 15.8 years for NAFLD patients and 16.9 years for controls), 59 patients with NAFLD died for a mortality rate of 5.5/1000 person-years compared with 36 deaths among the controls for a mortality rate of 0.65/1000 person-years.
The absolute risk of overall mortality over 20 years was 7.7% for the NAFLD cohort and 1.1% for the controls, “which translated to 1 additional death per every 15 patients with NAFLD, followed for 20 years,” the authors wrote.

As NAFLD severity increased, so did the risk of overall mortality. Patients with simple steatosis had a 20-year absolute risk of mortality that was 5.7% higher than controls and patients with NASH had a 20-year absolute risk of mortality that was 8.4% higher.

Patients with NAFLD, compared with controls, had increased mortality due to:
  • Cancer (1.67 vs 0.07/1000 person-years)
  • Cardiometabolic disease (1.12 vs 0.14/1000 person-years)
  • Liver disease (0.93 vs 0.04/1000 person-years)
  • Other/exogenous causes (1.8 vs 0.4/1000 person-years)

What are the causes of nonalcoholic fatty liver disease?
  • Overweight or obesity.
  • Insulin resistance, in which your cells don't take up sugar in response to the hormone insulin.
  • High blood sugar (hyperglycemia), indicating prediabetes or type 2 diabetes.
  • High levels of fats, particularly triglycerides, in the blood.

Recurring Resources

Medical Stop-Loss Providers Ranked by 2019 Annual Premium Tops $23 Billion

MyHealthGuide Source: MyHealthGuide, 5/23/2020

The Medical Stop-Loss Provider Ranking has been updated based on 2019 Annual Premium.  In addition, Rankings from years 2018, 2017 and 2016 have been incorporated into a single table.
  • The top 96 stop loss providers are ranked.
  • The Medical Stop-Loss Provider Ranking table data reflect Direct Earned Premium from the "Accident and Health Policy Experience Exhibit" ("Supplemental Pages, Insurance Expense Exhibit” section) of publicly available Statutory Reports filed annually by each insurance carrier.
Click here to view The Medical Stop-Loss Provider Ranking

Stop Loss Premium Growth

Stop Loss premium based on 2019 annual premium is $23,588,932 (thousands), a 57% over 2016 annual premium of $15,004,224 (thousands) for a compounded annual rate of 16.2%.  Stop Loss premium totals by year:
  • 2019 - $23,588,932 (thousands)
  • 2018 - $19,849,233
  • 2017 - $16,451,079
  • 2016 - $15,004,224
Top 20 and Ranking Changes

The top 20 stop loss providers based on 2019 annual premium:
  1. Cigna
  2. CVS Health Corp (includes Aetna acquisition)
  3. UnitedHealth Group
  4. Sun Life Financial
  5. Anthem
  6. Tokio Marine HCC
  7. Voya Financial Inc.
  8. HCSC
  9. Symetra
  10. HM Insurance
  11. Humana
  12. Companion Life/Blue Cross Blue Shield of SC
  13. Swiss Re
  14. W. R. Berkley Corp.
  15. Western & Southern Financial
  16. Fairfax Financial (CF Ins)
  17. Blue Cross Blue Shield of MI
  18. QBE
  19. Nationwide
  20. National General Holdings Corp
In the new updated 2019 ranking, there were
  • 14 providers that did not change their ranking position from 2018.
  • 41 providers moved up in the ranking.
  • 26 providers moved down in the ranking.
  • 12 providers are new the ranking.

Upcoming Conferences

July 19-21, 2021 Virtual Conference
HCAA's TPA Summit 2021 presented by Health Care Administrators Association, Information

July 20-22, 2021
The Montana Captive Insurance Association, Inc. (MCIA) Annual Conference.  in-person. Whitefish, MT.  Information.

July 27, 2021 - Webinar 11:00 am PDT
“Transplant and Reference Based Pricing 101: Everything You Need to Know from Our Experts” a Fireside Chat, presented by 6 Degrees Health for a Fireside Chat featuring Scott Ray, Jill Miller, Donald Lee, and Heath Potter of 6 Degrees Health. Our team of industry experts have over 50 years of combined transplant and reference based pricing experience and will discuss best practices and steps you can take today and in the future to impact plan performance.  Click here to register

August 25-27, 2021
MASI 23rd Annual Fall Conference presented by Mississippi Association of Self-Insurers (MASI). Make plans now to join your fellow MASI members and friends at the 23rd Annual MASI Fall Conference. This year's meeting, MASI-ssippi, will be a celebration of everything great about Mississippi. Be prepared to enjoy true Southern hospitality while learning the latest from the self-insured workers' compensation and health insurance industry. Beau Rivage Casino & Resort / Biloxi, Mississippi.  Click here for more information and to register.

September 22-23, 2021 - (SPBA Members Only)
SPBA Fall 2021 presented by Society of Professional Benefit Administrators (SPBA).  Kansas City Marriott, Country Club Plaza in Kansas City, MO.  Information: 

October 3-5, 2021
National Conference & Expo presented by Self-Insurance Institute of America. If public health conditions improve sufficiently later next year, SIIA will supplement the virtual format with in-person components to allow for an additional option for those who would like to participate in that way. Watch for announcements likely later next spring. Austin, TX. Information:

October 25-28, 2021
WLT Software 2021 Spooktacular Client Conference & Halloween Networking Ball.  It's back, and at the beach! The long-awaited WLT Software Client Conference is back, and the benefits administration solutions leader can’t wait to host all Clients, partners, and friends once again. This year's event falls on, no other than Halloween Week and will be hosted in beautiful Clearwater Beach, Florida. Join the team beachside or poolside for four days full of education, training, and even a Halloween Networking Ball! Not to mention acclaimed the Client Conference roundtable, where Clients are encouraged to share feedback and suggestions that will be presented directly to the WLT Software team. Not to mention special guest speaker Matthew Albright, Chief Legislative Affairs Officer for Zelis Healthcare, who will be sharing the ins and outs of the upcoming legislation the No Surprises Act and Transparency in Coverage requirements. Clearwater, FL.  Contact for more information about attending.


February 21-23, 2022

HCAA's Executive Forum 2022 presented by Health Care Administrators Association, Bellagio, Las Vegas, NV.  Information

July 18-19, 2022
HCAA's TPA Summit 2022 presented by Health Care Administrators Association, Hyatt Regency St. Louis at The Arch, St. Louis, MO. Information


July 17-18, 2023

HCAA's TPA Summit 2023 presented by Health Care Administrators Association. Hyatt Regency, Dallas, TX. Information


Job News

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Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
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