• Empowering Plans
    Since 1999
Welcome to The Phia Group
The Phia Group, LLC is an experienced provider of health care cost containment techniques offering comprehensive consulting services, legal expertise, plan document drafting, subrogation and overpayment recovery, claim negotiation, and plan defense designed to control costs and protect plan assets.  

Learn with Us

Confront the issues that impact our industry by addressing conflicts that threaten plan operations and viability, coordinating relationships, and providing legal guidance.

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Plan With Us

“Setting the Industry Standard for Plan LanguageTM” by combining cutting edge technology with forward thinking creativity, and a client-centric customized approach.

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Save With Us

Offer flexible service options driven by client needs, leverage innovative methods and proprietary technology to identify more opportunities and master applicable laws, yielding results unmatched by anyone else.

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Protect The Plan

Protect forward-thinking plan sponsors against unjust claim costs and fiduciary liability, while protecting participants against balance billing.

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Recent Webinars

Recent Posts

  • Back to Basics: Plan Documents 101 (Part 2)
    Posted 2 weeks ago
    When we think of hot topics in the self-funded industry, plan document drafting is hardly the first thing that ...
  • Back to Basics: Plan Language 101
    Posted last month
    Most situations that involve self-funded benefit plans revolve around language within the plan document. Whether deciding if a service ...
  • The Tangled Web of Contracts
    Posted 3 months ago
    The self-funded industry is made up of a complex system of contracts, and navigation across them is anything but ...
What others are saying
  • “I would like to congratulate both of you and everyone at The Phia Group for sponsoring the most beneficial conference I have attended in years. Fortunately, I brought my management team as well and they were exposed to a wealth of information and expertise firsthand, in an amazing setting. The opportunity was afforded due to your generosity and passion for our industry, and I am confident your efforts will continue to be recognized and appreciated going forwards. I have become acquainted with your team, primarily from attending other conferences and through our association with PHX. You have assembled an extraordinary staff of highly-motivated, dedicated, and talented employees, which was obvious to everyone who attended this meeting, and I look forward to partnering with The Phia Group to provide additional value to our organization as well. Congratulations on 10 successful years, and thank you again for all you are doing to promote and strengthen the self funded industry.”

    Marilyn PalmieriPresident, CEO
    HealthCare Solutions Group, Inc.
  • “We appreciate being a client. Your group does everything first class and we can depend on the information and service. Loved the seminar and we are excited to have the follow-up access and answers to the questions that were posed. Keep up the “excellent” work on behalf of the industry”

    David W. SmithPresident
    INTEGRA Administrative Group
  • “The Phia Group is one of our most active and engaged members. The company consistently supports the association in a variety of ways and by doing so has established itself as an industry leader.”

    Mike FergusonChief Operating Officer
    Self-Insurance Institute of America, Inc.
Phia Spotlight
Passion For Subro Blog

U.S. Supreme Court Rules Against Subrogation Rights … What Now?!!

Wed, 20 Jan 2016 16:44:04 +0000

EARLY IDENTIFICATION, INTERVENTION AND STRONG PLAN LANGUAGE HAVE NEVER BEEN MORE IMPORTANT!!! In the last hour, The Supreme Court of the United States issued an 8-1 decision in favor of the plan participant in the case of Montanile v. Board of Trustee of the National Elevator Industry Health Benefit Plan (Click to read the decision). In the latest case regarding subrogation to reach The Highest Court in the Land, The Court ruled that the Plan could not recover from Montanile after he received a third party settlement and spent the money. Make no mistake, third party recovery just got much more difficult. If benefit plans don’t have air tight language, and proactively intervene before a plan participant spends settlement proceeds, the Plan is out of luck! The Phia Group is here to help! More Details to Follow! Contact Us at PGCreferral@phiagroup.com to learn more about what you can do to protect your Plans’ Assets! “Learn With Us, Plan With Us, Save With Us. Protect the Plan”

The Phia Group’s January Webinar: Available for Download!

Wed, 20 Jan 2016 15:19:07 +0000

We’re proud to announce that the video, audio, and a PDF version of the slide deck from today’s presentation are all available for download here: (https://www.phiagroup.com/savingstoploss). If you were able to tune in, we hope you enjoyed the presentation; if not, we hope you enjoy it once you do get a chance to view it – and feel free to share it if you’d like. Please also let us know if you’ve got any questions or feedback for us. We hope to see you in attendance at our next webinar, on February 16th, 2016 at 1:00pm EST; the registration link isn’t available yet, but you’ll receive an invitation via email soon enough. (Block off your calendar now, though!)

The Phia Group’s January 2016 Webinar – Last Chance to Register Now!

Mon, 18 Jan 2016 17:46:03 +0000

TOMORROW! Saving Stop-Loss: Protecting a Key Self-Funding Ingredient in a Hostile World TOMORROW! Tuesday, January 19th, 2016 1:00 PM (EST) to 2:00 PM Last Chance – Register Now! Stop-loss insurance is one of the – if not the – most important piece of the self-funded puzzle. Attempting to predict how stop-loss will react is what every plan contemplates when examining claims; every administrator asks the same question, “Will stop-loss reimburse the claim, if we pay it?” Stop-loss is vital to self-funding – because catastrophic claims can bankrupt an employer in the blink of an eye. This dependency on stop-loss has led to our present situation; self-funded plans look to stop-loss to instruct them regarding payments, and those who seek to harm the self-funded industry do so by attacking stop-loss. Forces – both internal and external – conspire against stop-loss carriers. From regulators seeking to eliminate self-funding, to carriers that have taken a more heavy handed approach to cost containment; ensuring that stop-loss continues to exist and thrive, while working harmoniously with the plans they protect, is the difference between comfortably self-funding and being forced into the fully-insured market. Join The Phia Group’s legal team on Tuesday, January 19, 2016 from 1:00 PM to 2:00 PM (EST) as they provide first-hand insight into our reliance upon stop-loss, as well as threats to that industry, including what carriers need to worry about in 2016 and what to look for – and look out for – regarding stop-loss options. Last Chance – Register Now! ATTENTION: If you do not receive a confirmation email shortly after registration with webinar log-in details, check your spam filter.

Secrets to Making Reference-based Pricing Work

Mon, 18 Jan 2016 15:39:20 +0000

MyHealthGuide Source: Adam Russo, Esq.,1/14/2016, Thompson Information Services Blog In order for reference-based pricing (RBP) to work, health plan sponsors should do it in a way that involves implementing best practices for cost analysis, claim repricing, plan design, patient advocacy (including balance billing protection when necessary), and member education. Ways to Make RBP Succeed Employers, administrators, brokers and courts have begun to realize that determining the value of a health care service must involve something more than considering only a provider’s billed charges. More and more courts are accepting evidence based on the reasonable and customary value of the claims and not what the facility actually billed. A health care provider’s billed price for particular services is not necessarily representative of either the cost of providing those services or their market value. The reasonable value of services (to be used to set the RBP payment your plan will pay) must consider evidence of the full range of fees that hospitals charge and actually accept as payment from private payers, Medicare or patients themselves. Since Medicare reimbursement is almost universally accepted in the market, paying any willing provider the Medicare rate plus a percentage is an objectively reasonable approach to providing the broadest possible provider access for RBP plan participants. The problem is that these same facilities have been getting so much more than this from large insurers and networks for so long. Toss Out the Red Herring Since U.S. Department of Labor issued frequently asked questions on RBP in 2014, the argument was made that RBP must be illegal since the Affordable Care Act limits the out-of-pocket maximum that a patient can have. But the issue is that the agency wrote the ACA rule with in-network claims in mind. Part of this confusion stems from the reality that networks have been so pervasive for so long that people cannot conceive of a world without them. It is important to understand that a claim subject to RBP in many cases has no network and would be viewed under a typical network scenario as an out-of-network claim. Thus, according to DOL, balance billed amounts resulting from non-network claims are not included in the individual’s out-of-pocket cost limitations. Protect Members from Balance Billing This doesn’t make balance billing the patient desirable. The plan doesn’t want to be price gouged by facilities but also doesn’t want its patients to be balance billed. Plans have to play a balancing act, which is not easy to do. If you are the patient, you start thinking that you are a pawn in a chess match when it comes to RBP. We repeatedly hear patients say they thought they had insurance and that getting balance billed must be a mistake. The upset patient runs to his or her HR department demanding answers, and in the end doesn’t care what the plan pays as long as he or she doesn’t get his or her credit scores ruined. Employers typically do care about the employees’ well-being but also care about the plan’s finances. They realize that the more the plan has to pay, the pricier health insurance becomes. However, they have to balance this with understanding that balance billing is bad for business and for public relations. Patient Advocacy Advised The best RBP programs should have a patient advocacy process. The process should involve providers of all types. Any such negotiation would still require the plan administrator to determine any maximum payable amount within the parameters the plan defines for reasonable and appropriate reimbursement. Also, the plan administrator should be able to offer to cover any patient deductible. Also, a comprehensive patient advocacy program will have information on providers in many service areas across the country and will help RBP plan members find providers that are unlikely to balance bill for their services. Medical tourism is a favored aspect of RBP plans for the same reason that RBP plans are better for members who travel outside their normal service area. An RBP plan member who seeks care outside his or her regular service area is more likely to be able to find a provider that will accept RBP as payment in full. Plan sponsors don’t want to pay beyond their RBP payment, especially if their stop-loss carrier limits its reimbursement to RBP levels. Under that circumstance, payments beyond RBP would sap the plan and not the stop-loss insurer. Bring Providers Along Good RBP programs have direct contracts with out-of-network facilities, and plan documents that give the plan administrator leeway to negotiate with providers. Specifically, successful RBP plans have contracts in which out-of-network facilities agree to accept the plan’s RBP rates. At the same time, however, a readiness to negotiate claims when needed can prevent balance billing and collections. Facilities accepting the plan’s RBP rate sets off a virtuous chain of consequences: no balance, no patients being balance billed, no complaints and no scrutiny. Further, plan language must: 1. allow for the use of RBP; 2. describe the sources of pricing data to be used by the plan; and 3. address assignment and appeals. If those and related questions are not answered, third parties will be able to find ways to refute the plan’s payment methods. In order to do this correctly, you need to have great plan drafters, as well as experts at facilitating provider contracting and claim negotiations. Patients must be educated about the process and understand the type of RBP practices involved. They must know whether the plan has a physician-only network or a narrow network, and what direct provider contracts exist. The plan should teach them what to do if they are balance billed, including: (1) who pays the balance and (2) what the worst case scenarios are. Percentage of Medicare Traditional networks have failed to stem the rising costs of health care. This has the overall effect of reducing access to health care. Further, networks have encouraged a pricing system where providers charge one thing for their services but accept an entirely different payment from plans […]

Florida Business Coalition Set to Revolutionize Health Benefits Purchasing

Mon, 18 Jan 2016 15:32:36 +0000

By Dave Chase Template Set for Business Coalitions on Health Around the Country After many years of de minimis impact on slowing healthcare’s hyperinflation, business coalitions are doing a strategy reset . Historically, the business coalitions I’m familiar with have been “captured” by industry (pharma, health plans, etc.) who have a vested interest in ensuring healthcare spending continues unfettered. Read more…  

The Phia Group’s January 2016 Webinar – Register Now!

Fri, 15 Jan 2016 20:14:38 +0000

Saving Stop-Loss: Protecting a Key Self-Funding Ingredient in a Hostile World Tuesday, January 19th, 2016 1:00 PM (EST) to 2:00 PM Join Us – Register Today! Stop-loss insurance is one of the – if not the – most important piece of the self-funded puzzle. Attempting to predict how stop-loss will react is what every plan contemplates when examining claims; every administrator asks the same question, “Will stop-loss reimburse the claim, if we pay it?” Stop-loss is vital to self-funding – because catastrophic claims can bankrupt an employer in the blink of an eye. This dependency on stop-loss has led to our present situation; self-funded plans look to stop-loss to instruct them regarding payments, and those who seek to harm the self-funded industry do so by attacking stop-loss. Forces – both internal and external – conspire against stop-loss carriers. From regulators seeking to eliminate self-funding, to carriers that have taken a more heavy handed approach to cost containment; ensuring that stop-loss continues to exist and thrive, while working harmoniously with the plans they protect, is the difference between comfortably self-funding and being forced into the fully-insured market. Join The Phia Group’s legal team on Tuesday, January 19, 2016 from 1:00 PM to 2:00 PM (EST) as they provide first-hand insight into our reliance upon stop-loss, as well as threats to that industry, including what carriers need to worry about in 2016 and what to look for – and look out for – regarding stop-loss options. Join Us – Register Today! ATTENTION: If you do not receive a confirmation email shortly after registration with webinar log-in details, check your spam filter.

What’s behind the Clinton-Sanders health care fight?

Thu, 14 Jan 2016 20:51:49 +0000

By Eric Bradner and Tami Luhby, CNN The two leading Democratic presidential candidates’ escalating feud over health care has become a defining issue in the 2016 primary campaign as they approach the final debate, Saturday in South Carolina, before voting begins. Here’s a look at what the fight’s all about:

A few Ala. counties halt marriage licenses to gay couples

Tue, 12 Jan 2016 18:13:36 +0000

By Brian Lyman, Brad Harper and Andrew Yawn, The Montgomery (Ala.) Advertiser MONTGOMERY, Ala. — An order from the chief justice of Alabama’s Supreme Court aimed at thwarting the availability of same-sex marriage in the state seems to be having little effect, according to calls to counties Thursday. Read more…

Obama vetoes Obamacare repeal effort

Tue, 12 Jan 2016 18:09:34 +0000

By Dan Cook As expected, President Barack Obama vetoed a Republican-backed measure that would have repealed the Patient Protection and Affordable Care Act. Read more…

First Quarter Newsletter 2016 – The Stacks

Tue, 12 Jan 2016 12:00:12 +0000

The Power of the Plan Document, by Adam V. Russo, Esq. Just the other day I heard the strangest comment from someone that I truly respect and was kind of shocked to actually hear. One of the top executives in the self insured industry was talking to me about self funded employee benefit plans and simply stated that they did not believe that plan document design and ease of use of was required to properly operate a TPA. In addition, this individual specifically stated that technology and software are not needed in the design of summary plan documents and are not necessary for the proper operation of a TPA in administering their plans. I was shocked to say the least. While I respect this person’s opinion, it is clear to me that they do not understand the full scope of a wide spread industry problem. The number one reason why plans are sued, TPAs are brought into litigation, and stop loss carriers deny claims or push back for more information is the fact that plan documents are out of date, out of compliance, contradictory, and are just too confusing to comprehend. Plan documents are created to instruct an administrator what to do with a claim. If the plan is wrong, claims are paid in error – it’s as simple as that. My firm represents tens of thousands of self funded employee benefit plans and the reality is that the number one issue facing these plans is that their plan documents are not up to par. A vast majority of the issues that our attorneys deal with have the same foundational issue – poor plan design and language. Simple technology and software leading to consistent language and process is the key to resolving the issues we see daily. Redlining Can Cause Pain…Lots of It As an attorney, I learned many, many years ago the power of redlining. It allows a drafter of a document to edit, comment , add and delete areas of a document as needed and it shows who did the change and why. It is a great tool until you have five or more redlined changes by five different people. This is the part of plan document drafting that most executives do not understand. It isn’t just one person creating the document as if it was me writing this article. It involves many people, from outside attorneys to account representatives to eligibility personnel to human resource people to stop loss specialists. Many times up to ten people take a look at the draft of a plan document and that is a lot of redlining to go through. You end up with some people revising the fourth edit while others are red lining the original. It leads to chaos and most importantly – mistakes. In the past month alone, my office has seen over twenty examples of the wrong plan document being approved and accepted by the plan sponsor as their final document. All of it due to the wrong version of the plan document being redlined or redlines and changes not being deleted or accepted. It’s a constant challenge when there are just so many eyes on a particular document with various versions and editions being passed around via email. There is an easy way to stop this and it involves the use of technology through plan document software that is available in the market place. I have seen too many occasions when the plan approves a version of the plan document that didn’t incorporate redlined changes from other versions just because there were too many versions of the documents on different word documents. By using the proper plan document software, there is one template that every person can look at real time with all comments and changes available to be easily seen by all of the users. It’s a no brainer when it comes to creating a single plan document that will need many updates and changes. When you involve a plan sponsor, a broker, a stop loss carrier, a plan builder, and a TPA there will be many different people wanting to share their two cents. Having access to plan document software is the only way that all of these various needs can be accommodated without making costly mistakes to the plan design. Let’s not forget that the plan sponsor has a fiduciary duty to be prudent with plan assets and to follow the terms of the plan document. Well what do you do if the plan document has missing or incorrect information? I guess you pray that you aren’t sued by anyone for a claim error. Stop Loss Issues Too often when TPAs, brokers and plan sponsors talk about designing the perfect plan document, they forget one of the biggest pieces of the self funding puzzle – the stop loss policy. Think about it for a moment. What makes the perfect self funded plan go bad or worse, go bankrupt? Large claims that the plan cannot afford to pay. This is the primary reason why self funded plans end up becoming fully insured again or join the exchange. The reason why self funded plans purchase stop loss coverage is to protect them from large and unexpected claims. They purchase a stop loss policy expecting large claims to be covered by the stop loss carrier. So what happens if a large claim comes in that isn’t reimbursed by the carrier and the plan is stuck with the large bill? Well, you guessed it; the plan ends its courtship with self funding and goes back to purchasing fully insured policies from the carriers. Self funding has left a bad taste in their mouths…forever. While the plan document may be perfect, if the stop loss policy doesn’t mirror the terms of the plan document, then the terms of the plan really don matter when it comes to a large claim. So while the claim may be payable under the terms of the plan, it may not be payable […]

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