PBOR legislation, a comprehensive package of requirements on managed care
the Healthy New York plan.
Cross/Blue Shield affiliated companies. With respect to laboratory and radiology services, the Companys
NCQA
claims processing errors. utilization of medical services, including, but not limited to, higher
Most notable was an option that Wiggins dubbed the Freedom Plan. (Oxford NJ) and Oxford Health Plans (CT), Inc. (Oxford CT) and through
November-05
Sales/Admin
Oxford
benefits, financial condition and marketing practices. The Company offers its products through its HMO subsidiaries, Oxford Health Plans (NY), Inc. ("Oxford NY . referrals, eligibility information and other Internet provider connectivity
The Company maintains regional broker business unit representatives
subsidiaries.
in future periods;
significant punitive damage award, could have a material adverse effect on the
In fact, Oxford was ranked tops in customer satisfaction surveys of HMO members and was also regarded by many health care organizations as one of the easier health plans with which to work.
generally ceased except in unusual circumstances, which generally has led to
maintenance organizations (HMOs), preferred provider organizations (PPOs),
changes to the Medicare program, including the addition of a prescription drug
to keep up with the cost of health care, it is possible that the Company may
increases for Medicare members have not kept up with the increases in health
In an effort to control increasing medical costs in its Medicare programs,
Contact us with any questions today. renewed or that the Company will achieve the same level of accreditation in the
Jersey and Connecticut service areas providing for inpatient and outpatient
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Under the New Jersey law
breach of contract and violations of New York General Business Law, Public
new systems to support the Companys operations and improving service levels
In addition, CMS regulations prohibit HMOs with
The risk of potential
events, coupled with new legislation in New Jersey and proposed legislation in
$195million over the agreement term.
of Investors Guaranty Life Insurance Company, a domestic California insurance
and the radiology agreement expires on February28, 2003. The Company believes that under the 1997 Act, future
Cost-containment and risk-sharing arrangements
additional prompt pay fines in the future. agreement by nine New Jersey HMOs, including Oxford NJ, to cover routine
to cover 90% of certain of the paid claims for the New York Mandated Plans
In the fourth
employer group renewal prospects and its ability to increase premiums.
Oxford, Oxford Health Plans (NY), Inc. (Oxford NY), KPMG LLP (Oxfords
who work directly with the independent agents and brokers. violated Section10(b) of the Exchange Act and Rule10b-5 promulgated
physician complaints and for retrieval of data when conducting focused studies. plans to provide coverage for mental health conditions generally at the
6, 1996 through December9, 1997 (the ClassPeriod), purchasers of Oxford
If such limitations are
investigations and inquiries by Federal and state governmental agencies.
Local physicians serve
January1, 2002, the Company exited the Medicare line of business in Long
Under the new HIPAA privacy rules, the Company will now be required to (a)
Ancillary Providers
MedUnite, Inc., including $7.2million in 2001 and $1million in 2002.
health care industry, and the impact on the Company of legal proceedings and
Currently it operates as a subsidiary of UnitedHealth Group Incorporated.
The amended settlement further provides that
risk-sharing arrangements, epidemics, acts of terrorism and bioterrorism or
premium revenues received from New York business.
Connecticut Unfair Trade Practices Act (CUTPA) and negligent
advise the Company on the development of treatment and payment policies
76,000
HIPAA, DHHS has issued final rules standardizing electronic transactions
Effective July1, 1999, New York enacted a law establishing a right
reimbursement by CMS that could reduce the reimbursement received by the
Explore health plans for your family, including short-term gap coverage and more. The largest HMO commercial employer group accounted for 5.4% of total HMO
passed separate versions of the PBOR. Although the Senate and House versions of the PBOR legislation have significant
for employers with 50 or fewer employees and individuals who have generally not
and admitting hospitals for malpractice history, disciplinary actions and/or
The Womens Health and Cancer Rights Act of 1998 requires health
employer-funded benefit plans (self-funded health plans).
$195million over the agreement term. costs for covered services and to contribute in part to the Companys ability
Hill and Montefiore Hospitals and with a provider organization. 2002. insurers based upon the demographic makeup of the insurers membership base
As a result of the Day of Service-Decision Making
other requirements relating to physician incentive plans that place physicians
For example, CMS has prohibited the transmission of Medicare
The New York State Insurance Department (NYSID) has created Market
premiums in 2001 and 12.6% in 2000.
Examples of
enrollment in the Companys service areas and, in some cases, greater financial
NYSID fine policy referred to above. insurance carriers of group and individual commercial policies that
at rates established in the agreement. injunction enjoining the Company from pursuing the complained of acts and practices,
October-02
(Reliance), was placed in liquidation in October 2001 by the Commonwealth
benefits and exiting additional counties. However, as of
Plaintiffs in all of these
Premium rate increases in a particular region that are lower than the
The re-credentialing review
address the changing needs of its membership, there can be no assurance that
State
to keep up with the cost of health care, it is possible that the Company may
implement a risk adjusted mechanism on its monthly member payment to
the defendants from pursuing the complained of acts and practices.
company currently providing health benefit plans primarily in New York, New
compliance to be approximately $10million in 2002 and
and has provided information in response to this informal request. licenses granted by the Departments of Insurance of New York and Connecticut,
through peer review and ongoing review of performance indicators. (Oxford NJ) and Oxford Health Plans (CT), Inc. (Oxford CT) and through
Affiliates, subsidiaries or branches (must be included for purposes of participation) Legal name and location Number of full-time employees in this company IBNR estimates; Inability to control health care costs. By 1987, its first full year of operation, Oxford generated premiums of about $5.6 million. including internal and external appeals, and financial condition.
In order to maintain this status,
Hospital Arrangements
which significantly affects its operations includes, among others:
As previously reported, on or about July20, 1999, the New York Attorney
On April26, 2001 the Company filed motions to stay both actions
or cover the costs stemming from such PBOR legislation or the other costs
Membership amounts are included in the HMO Plan membership.
currently considering regulation or legislation relating to mandatory benefits
(such as mental health), provider compensation arrangements, health plan
limited to the following pending matters: an annual on-site survey by the
paid and/or the disgorgement of profits, in addition to injunctive relief. Connecticut Unfair Trade Practices Act (CUTPA) and negligent
Company in Connecticut Superior Court (the Connecticut derivative actions)
affordable by focusing on health care costs, (2)developing new products to
Jersey and Connecticut. The Amended Complaint: (i)alleges that defendants
The economy and markets are "under surveillance".
Exclusive of the Physician Group and the cost containment arrangements
not-for-profit HMOs, PPOs, and indemnity insurance carriers, some of which have
In New Jersey and Connecticut, each member receives Freedom Plan
There have been recent legislative attempts to limit
penetration in its current market area and contiguous geographic markets, and
increases. relationships with hospitals, the Company maintains the Day of Service-Decision
they operate.
products. premiums earned during 2001, while the ten largest HMO groups accounted for
products.
recovered by Oxford alleged to have been collected in violation of New Jersey
The Company believes that the network of
York under a grandfathered POS plan (together with the New York Mandated Plans,
Square Feet
(See Section II.B.3 above.) The Company is continuing to explore other risk-sharing or
community and obtain physician input in its practices. and financial challenges for the Company and could be adversely affected
The Freedom Plan had approximately 1.13
effect of such cost-containment agreements in 2001 was to reduce the Companys
be able to mitigate or cover the costs stemming from such litigation. additional prompt pay fines in the future. Such community rates are generally revised
Administrative
premiums earned during 2001, while the ten largest HMO groups accounted for
Other Matters
among other things, enacted modest increases to the payment formula for
utilizes a hospital bill audit program that has yielded savings with respect to
Physicians who want to jointly negotiate fees may do so only with a
Network physicians, hospitals and other health care
significant penalties.
that affect performance of important functions, including claims payment and
In March 2000, the
purposes of these statutes and regulations, generally control means the
violated Section10(b) of the Exchange Act and Rule10b-5 promulgated
and combine the relevant community rate with traditional indemnity insurance
cost to comply with any injunctive or other non-monetary relief or any
comply with a variety of requirements concerning their use and disclosure of
5250 West Century Boulevard services provided to its members by performing member and physician
restrictions, not all functions are available in all markets or for all
officers and directors with several subpoena duces tecum requesting documents
State Insurance Department (NYSID) and licensed as a foreign insurer by the
significant public and political support for reform of managed care regulation. complete federal preemption of state laws, but rather preempt all contrary
providers, advise the Companys Chief Medical Officer concerning the
developed pattern of treatment standards to identify procedures that were not
generally, after exhausting an appeal through an independent review board, a
Judge Brieant consolidated the class actions for pretrial purposes under the
value to its constituents and ease the administration of, streamline costs
totaled approximately $251million in 2001 and $240million in 2000 for
Oxford believes that the target market for the Freedom Plan is small to
network, is competitive in size and quality with networks of certain other
Health Plans, Inc. legislation that would create an accuracy threshold, such proposed fines could
Company launched its website,
hospital diagnosis related group payments and other surgical payments. In 2001, the Company also paid a fine of
Other recent state legislation which governs the Companys business and
Company has developed a network of physicians and other providers to serve its
oxfordhealth.com, prospective enrollees, benefit administrators and brokers can
Hospital Arrangements
total as compared with nineteen self-funded groups in New York and eleven in
of Insurance for any change of control of Oxford NY or the Company and the
45,000
Company Description: "Oxford" may conjure images of stuffy learning institutions or stiff-collared shirts, but Oxford Health Plans is anything but stuffy or stiff. period August 1995 through the present. providers to determine compliance with Oxford standards.
authorizes referrals for specialist physicians, diagnostic tests and
The Companys
on February20, 2002. and 1999, respectively, relating to prompt pay issues, primarily related to
statutes and regulations in addition to meeting the requirements established
additional prompt pay fines in the future.
assurances as to the ultimate accuracy of such estimates. Managements Discussion and Analysis of Financial Condition and Results of
could adversely affect the Companys operations.
Oxford. treatment of illnesses not requiring referrals, as well as periodic physical
enhancing the functionalities of its Internet offerings. Oxford Health Plans (CT), Inc. is domiciled . criteria outlined in the regulations. coverage guidelines as the basis for denials; (iii)the inappropriate use of
the defendants from pursuing the complained of acts and practices. The coverage under the new policies is in addition to
subject to compliance with risk-sharing regulations adopted by CMS and the
Oxford also continues to cover individuals in New
the specialty as recognized by the American Board of Specialties) or become
The Amended ESI Agreement further
. including changes to reimbursement of HMOs.
self-funded plans directly to employers. You cant process a claim like that, he observed. Plan premiums earned in 2001.
On September7, 2000, the Connecticut Attorney General filed suit against
Oxford Health Plans, Inc. is a subsidiary of UHG. The Companys Liberty Plan is a POS health care plan. plans Medicare members.
On October2, 1998, the co-lead plaintiffs filed a Consolidated and
direction of the management and policies of an entity.
Federal and state laws and regulations directly applicable to
In March 2000, the
on February20, 2002.
pursuing, will simplify and streamline its processes and provide added
Primary care physicians provide preventive and routine medical care
substantial number of documents in response to the subpoena, and expects to
legislation that would create an accuracy threshold, such proposed fines could
of approximately $3.6million that was included in income for the year ended
(the Patel action).
been filed in 1999. could have a material adverse effect upon the Company and its results of
relationships and arrangements with hospitals and physicians may limit the
issues can lead to data problems that affect the performance of important
their negotiation strategy.
Customers saw the highest-level service in the industry slip off, Smoler explained, adding a lot depends on how quickly we recover.. in the United States District Court for the District of Connecticut, on behalf
cost-containment agreements. and financial challenges for the Company and could be adversely affected
Medicare contracts provide revenues that are
network regardless of geographic need, hospital admitting privileges and other
Oxford Health Plans (NY), Inc. operates as a subsidiary of Oxford Health Plans, LLC.
handle physician inquiries. myuhc.com - Oxford group members.
approximately $7.5million to the Company, which is the amount such carrier
currently serves. During the year, the companys HMO membership climbed more than 80 percent in New York City and about 17 percent in the metropolitan area for a total subscriber base of nearly 65,000. insurance agents and brokers as of December31, 2001 who are paid a commission
Recently enacted legislation and the proposed regulatory and legislative
for estimated insurance recoveries that may not be
For a
For a
power with managed care payors. Other Matters
Health care provider network
possession, directly or indirectly, of the power to direct or cause the
the practices of the Company and others in the offering, issuance, sale,
members, whereby the Physician Group assumes certain risks for medical costs
generally coordinates the members health care needs. adversely affect the Companys results of operations, financial condition,
who are enrolled in plans governed by ERISA (the Connecticut Attorney General
The Company is also the subject of examinations,
exposure for specified procedures is generally at a negotiated aggregate per
Oxfordhealth.com
Management Company, Inc. United HealthCare Services of Minnesota, Inc. post-hospital care programs. Medicare business, the Company has entered into risk-sharing agreements with
The Company received an informal request on December9, 1997 from the
resources than the Company. statutes and regulations in addition to meeting the requirements established
There can be no assurance that such interruptions will not
and may be required to pay an additional amount in 2002. A
of various documents, records and materials in regard to matters relating to
consistent with a patients diagnoses, as well as billing abuses and
results of operations. The Company has
Doctors joined the HMO to gain access to, among other benefits, a large base of clients, while patients joined the HMO plan to receive lower health insurance premiums. health care providers or potential unionization of, or concerted action by,
the specialty as recognized by the American Board of Specialties) or become
Oxford directors and officers. predict the outcomes of these lawsuits, examinations, investigations and
maintenance organization, for cash consideration of approximately $19million. influence inappropriate utilization of certain services, including but not
Bloomberg Surveillance, covering the latest news in finance, economics and investments.
with the Company. premiums in 2001 and 12.6% in 2000. Primary care physicians provide preventive and routine medical care
principal executive offices are located at 48 Monroe Turnpike, Trumbull,
and the providers compliance with Oxfords administrative protocols.
Within the Cite this article tool, pick a style to see how all available information looks when formatted according to that style.
are board certified in their specialty (by passing certifying examinations in
Business Cautionary Statement Regarding Forward-Looking Statements. dividend payments, loans or other transfers of cash to the Company. Public Company ultimate impact HIPAA will have on its business and results of operations
established by the State of New York under the Health Care Reform Act of New
Company and certain of its directors and officers and the pending stockholder
."
provisions relating to, among other things, consumer disclosure, utilization
certain of its information technology services, including data center
New York, NY
injunctive relief. other states which provides or may provide physicians and other providers with
The suit seeks preliminary and permanent injunctions enjoining
Board certification is one measure of a
largest employer groups offering the Freedom Plan accounted for 4.9% of Freedom
to constrain the net increase in its total medical costs. of Oxford common stock and call options, and sellers of Oxford put options,
individual billing. market to offer POS and HMO coverage with mandated benefits to individuals (the
ultimate exposure from such costs through, among other things,
The Company maintains regional executive account representatives who work
agreement to provide any such relief. status to excellent for its New York line of business. 2001 of fining insurers as much as $1,750 for each prompt pay violation.
to CSC.
as the largest employer group contributed less than 1% of total premiums earned
carriers of $13.7million to the Company, with not more than $3.7million of
recoverable from Reliance. regard to certain special medical conditions, as defined in the New York
13,000.
procedures dictating health plan utilization management and claim payment
assurances as to the ultimate accuracy of such estimates. Other Products
in negotiation or arbitration over the reconciliations required, or other