Consulting & Services

As the laws affecting plan rights have changed, The Phia Group’s services have evolved to include specialized cost containment solutions and ensuring claim cost efficiencies. As The Phia Group expands its service offerings, its mission to reduce the cost of clients’ health benefit plans through innovative technology, legal expertise, and personalized service remains unrivaled.

Administrative Services Agreement Review

An administrative services agreement (ASA) that appropriately sets forth the obligations and responsibilities of both a Third Party Administrator and Plan Administrator is crucial. To avoid conflicts, the ASA must be drafted so that administrative tasks are clearly delineated. We can review your existing ASAs and identify potential pitfalls and provisions requiring immediate attention. In addition, we can draft a custom ASA designed to meet the needs of each client.

Third Party Agreement Review

Plans must obey the terms of the plan document and may not agree to step beyond the boundaries set by those provisions. Yet many third party entities expect Plan Administrators to exceed their fiduciary duties on a regular basis.

PPO Agreement Review

With respect to our PPO Agreement Review service, our attorneys will:

Stop Loss Agreement Review

With respect to our Stop Loss Agreement Review service, our attorneys will:

Gap Free™ Review

Benefit plan documents include provisions which describe when benefits will be available to plan participants. There are times when a stop-loss contract includes provisions in the applicable policy, which limit and sometimes exclude coverage even when the benefit plan provides coverage. As a result, there may be scenarios where a benefit plan provides coverage in accordance with the terms of the applicable plan document, but stop-loss is not available in accordance with the applicable policy or contract. This is what we call a gap in coverage.

Balance Billing and Medical Bill Review Consultation

Balance billing has become more prominent in recent years. Balance billing occurs when hospitals, clinics, doctor’s offices and other medical facilities bill patients for the balance between what they want to charge for services and what the plan has already reimbursed. Some States have enacted laws prohibiting this practice (in certain circumstances). As it relates to this practice, our attorneys will assist clients in third party negotiations to minimize conflicts.

Plan Administration Review and Defense

Too often are Plan Administrators persecuted for processing claims in accordance with the terms of the applicable plan document or policy.  Plan Administrators frequently find themselves defending their interpretation of the facts and application of the plan terms against appeals and complaints.  The Phia Group can help Plan Administrators with respect to plan interpretation and defense of administrative decision-making.

Stop Loss Claim Analysis

The claims process can only run efficiently when every organization involved in the process works together. The Phia Group can facilitate this process to ensure a smooth transition by obtaining and supplying necessary facts, reports, documentation, and answers related to a particular claim. By providing this service, reinsurance issues are resolved with an effective, timely, and proper flow of information.

Claim Processing Evaluation

While time is of the essence, plans need to ensure claims are processed in accordance with the terms of the plan document. To compliment a clients’ in-house quality assurance process, The Phia Group will review all plan documents with a focus towards claims processing. If claims are pending or denied, we determine what additional materials are needed to properly process claims. Our ability to understand the differences in exclusion, coordination of benefits, and eligibility provisions are invaluable when making claim processing decisions.

General Healthcare Consulting

The Phia Group’s consulting team offers deep expertise in many areas relating to the healthcare industry. We can quickly assess clients’ needs, recommend the best options, and work to create customized solutions for them.

IRO / External Review Consultation

The Phia Group can review applicable Independent Review Organization (“IRO”) agreements between an IRO and the benefit plan and/or Third Party Administrator to identify potential issues. If applicable, we can assist with the drafting of a stop loss agreement amendment to ensure that, if an IRO overturns a denial and payment is forced, stop loss will reimburse.

Dispute Resolution

In the process of administering a benefit plan, clients will sometimes become involved in disputes with third parties regarding a range of issues. The Phia Group’s attorneys can offer clients assistance in responding to grievances, negotiating with third parties, and managing third party conflicts. Whether it is by drafting correspondence for the administrator’s use, communicating with third parties on the administrator’s behalf, or even assisting in the defense of the administrator in Court, The Phia Group is here to help.

 

 

 

For additional information about The Phia Group’s Consulting Services, please contact:

Andrew Milesky
Director of Client Services
Phone: 781-535-5636
Email: amilesky@phiagroup.com