There are many legal concepts that affect your right to recovery. Opposing counsel will often attempt to reduce your subrogation interest by raising the Made Whole Rule or Common Fund Doctrine. How to address these complicated legal concepts differs depending on the strength of the Plan Document involved as well as the laws of a particular state and/or Federal Circuit. Therefore, arguments to reduce or eliminate a plan’s reimbursement right must be countered by experienced subrogation attorneys. Furthermore, if a case should proceed to litigation, only an attorney may protect plan rights in court.

Your subrogation and reimbursement rights are only as good as the plan language involved. If the plan member is killed in an accident that gives rise to plan reimbursement rights, can the plan recover from the estate? Only if the plan language so provides. Issues such as payment of claims for minors, offset of future benefits to compensate for a member’s unwillingness to reimburse the plan, and other specialized provisions must be addressed in the Plan Document. Plan language review and revision can add thousands of dollars in potential savings for plans; plans that too often lose or severely diminish recovery rights due to poorly drafted language. A lack of key provisions or inconsistent language can eliminate otherwise great subrogation opportunities.

Due to a lack of experience and resources, many plans fail to identify valuable subrogation and reimbursement cases. We will begin the recovery process by identifying potential recovery opportunities through the use of The Phia System, manual review by our experienced case developers, and educating your staff on the intricacies of subrogation case identification. The Phia Group understands the difference between subrogation and reimbursement and the costs and benefits of pursuing either approach. We first examine the facts and circumstances behind every case, and then determine the best course of action to maximize recoveries for the plan.

The Phia Group’s recovery percentages are much higher than the industry average. Every Phia Claims Recovery Specialist must master the recovery laws of all 50 states and every Federal Circuit. In addition, case strategy and final settlement authority must be approved by our attorneys. Meanwhile, The Phia System captures and uncovers more recovery opportunities than ever before. By having a better understanding of recovery laws and activating more cases, we are able to maximize client recoveries. This leads to savings that consistently exceed the industry average by wide margins.

In the process of investigating and reviewing claims during the act of subrogation and reimbursement, The Phia Group will undoubtedly identify claims paid by the plan that were actually the responsibility of another insurance carrier. An overpayment may have occurred, for instance, when the plan paid a provider for a claim that was the responsibility of the insured’s workers’ compensation carrier. Both the plan and the workers' compensation carrier end up paying the provider, who was, therefore, paid twice. We will contact the provider and use our resources to recover the overpayment, return the funds to you, and ensure that the same mistake is not repeated in the future.

The Phia Group’s overpayment services go beyond claims uncovered during subrogation analysis. We have an entire team dedicated to identification and recovery of overpayments, duplicate payments, and refunds due. We can recover and reset any such claim processing errors.

At the outset of our relationship, The Phia Group reviews all of your closed and active cases to ensure that the active cases are being handled properly and that closed cases with potential can be reactivated, and recoveries can be pursued. Your processed claims data is then analyzed through The Phia System, allowing us to examine recovery dollar potential and the number of subrogation files expected to be uncovered. Prior to beginning live data analysis, we will estimate expected savings. Upon approval, we review historical claims, customized to meet your wishes; analyze recovery of past processed claims; and review future claims as they are processed. Prior to sending any correspondence to the insureds, we manually review your claims system notes to ensure there have been no duplicate efforts, ensuring the goodwill of all parties involved. These subrogation audits have always been extremely successful in revealing previously undetected recovery cases and recouping past dollars lost.

While working with a client on recovery cases, The Phia Group staff reviews all Plan Documents, specifically focusing on the Right of Recovery, Plan Document Exclusion and Coordination of Benefits provisions. If claims are pended or denied rather than paid, we will determine what facts and documents are needed to process claims, whether the claims should be excluded, or whether the claims are the responsibility of another party. If an insured forwards claims for payment resulting from a car accident and payment is suspended for accident details, we will obtain the details, including accident reports.

There are various and extremely complicated exclusions in every Plan Document. Criminal acts, reckless activities, occupational injuries, and self-inflicted injuries are examples of exclusions that commonly can be applied, allowing denial of claims and protecting plan assets. There are more obscure exclusions to consider as well, such as injuries occurring while traveling or illness resulting from food intake. Not every plan has the same exclusions, making our ability to read and understand the subtle differences in exclusion provisions invaluable to you when making claim processing decisions.

Most plans with stop-loss coverage have encountered times when claims exceed the specific deductible and seek reimbursement from their reinsurance carrier. Reinsurers require an abundance of materials, including accident reports, identities of any other available medical payments coverage, proof of other funds’ exhaustion, a ledger of claims paid, and other accident details. Handling claims and pursuing reimbursement is enough to overwhelm any of your claims analysts. The added stress of reinsurance may become too much to handle. We understand and work with many stop-loss carriers, have experience dealing with and satisfying the needs of reinsurers, and frequently satisfy reimbursement requests. We will handle reinsurance issues, ensuring an efficient, timely and proper flow of information and analysis.

Workers’ compensation analysis and processing involves an understanding of coordination of benefits, plan exclusions, overpayments, and reimbursement rights. When an insured is injured at work, The Phia Group determines whether an occupational injury is excluded regardless of workers’ compensation availability, or if an exclusion applies only when the insured is entitled to workers’ compensation benefits. Next, we determine whether workers’ compensation carrier has accepted responsibility for payment of the claims. If so, we ensure that the carrier pays the claims first based on the plan’s Coordination of Benefits and Subrogation provisions. If you pay claims, later determined to be the responsibility of the workers’ compensation carrier, we will obtain reimbursement. We seek reimbursement either directly from the carrier or seeks refunds of the overpayments from the providers, having them resubmit their bills to the workers’ compensation carrier. Lastly, we will advise you to deny any future related claims and have those claims forwarded to the carrier for payment.

Before advising any client to pay claims, The Phia Group determines whether another carrier is primary for payment purposes. We investigate workers’ compensation, personal injury protection, medical payments coverage, spouses’ policies, homeowners’ policies, and organizational insurance funds such as school and business policies. We only advise payment of accident related claims when every other option has been ruled out. This entire process is done efficiently and in a timely manner to ensure compliance with prompt payment laws and provider discount requirements. All of this results in significant savings to you and your plans.

Frequently, in the process of pursuing other insurance carriers to coordinate benefits and seek reimbursement of claims, The Phia Group discovers that both the plan and another carrier have paid the same claim. The staff understands which state and federal laws apply to these situations. First, we assert your right to be the secondary payer and then initiate communication with the overpaid providers to obtain refunds. We have experience dealing with providers and know the requisite procedures necessary to recover duplicate payments.

In accident related subrogation cases, several pharmacy claims are paid by the plan. These prescription claims are recoverable, and unlike other recovery service providers, we proactively seek pharmacy claim details. Many plans do not recoup these savings based on the difficulty of managing and identifying these claims as being accident related. When working with us, integrating these claims allows for increased savings.