Phia GroupPhia Group Mediahttps://www.phiagroup.com/Media/PostsWegovy: Not Just a Weight Loss Drughttps://www.phiagroup.com/Media/Posts/PostId/1319/wegovy-not-just-a-weight-loss-drugBlog,Health Insurance,Healthcare CostsWed, 20 Mar 2024 12:45:42 GMT<p style="margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As if there weren’t enough buzz surrounding Wegovy. </span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Earlier this month, the wildly popular weight loss medication was approved in the US to help prevent life-jeopardizing cardiovascular events in people who are overweight, obese, and/or have a history of cardiovascular disease. The FDA’s stamp of approval for drugmaker Novo Nordisk to include cardiovascular benefits to Wegovy’s label meant it was the first weight loss drug to market itself in this manner. Now the million-dollar question (no pun, intended) becomes, will this label expansion make insurers feel more inclined to provide coverage? For good measure, will Medicare, <span style="background:white"><span style="letter-spacing:.25pt">currently barred by law from covering drugs for weight loss alone, be compelled to include Wegovy under its umbrella?  </span></span></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Currently, Wegovy costs over $1,300 per month before any applied discounts. Obviously, for nearly every single American, this out-of-pocket cost is prohibitively expensive – especially considering that many patients may need to take it for the rest of their lives. Furthermore, the age-old rule of supply and demand suggests that the price isn’t likely to drop anytime soon: amid soaring demand for Wegovy, Novo Nordisk has struggled to maintain an adequate supply, although the company has pledged to boost production for the balance of 2024. (<span style="background:white"><span style="letter-spacing:.25pt">Novo Nordisk has also asked European Union regulators to expand the use of the drug for heart problems; however EU regulators have not responded to the request.) </span></span>Unfortunately, many Americans – whether they are on private employer-sponsored plans or government-sponsored ones – have not been able to get financial relief from their insurance. Wegovy is simply too costly and – until this month at least – considered primarily to be a vanity drug. </span></span></span></span></span></span></span><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="background:white"><span style="letter-spacing:.25pt"></span></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">But now there appears to be irrefutable evidence that Wegovy doesn’t just help people get ready for their new stylish beachwear, but actually prolongs life by reducing the risks of cardiovascular issues surfacing amongst the most vulnerable patients. Consider that the recent FDA approval stemmed from a 17,000-patient study that demonstrated that people taking Wegovy had a 20 percent lower risk of experiencing a cardiac event than those taking the placebo. It is important to note that <span style="background:white"><span style="letter-spacing:.3pt">the participants already had some form of cardiovascular disease and it has been suggested that further studies need to be conducted to demonstrate whether there are benefits for those who haven’t experienced a cardiac event. Regardless, the salubrious effects are undeniable. As </span></span><span style="background:white">Dr. Melanie Jay, director of the N.Y.U. Langone Comprehensive Program on Obesity, told the New York Times, “when you treat obesity seriously in people who have a high burden of disease, you can get really good outcomes.” </span><span style="background:white"><span style="letter-spacing:.3pt">Meanwhile, the more common side effects of Wegovy, which have been reported to include nausea, diarrhea, vomiting, and constipation, do manifest themselves in many patients (for older ones, it is fairly common to experience a loss of muscle mass), but are not considered as severe as those that have been linked to weight loss drugs in the past.</span></span></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">Ultimately, many insurers and self-funded plans are now scrambling to justify how they can deny coverage of a medically necessary medication. </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">But aside from the optics, <span style="background:white"><span style="letter-spacing:.25pt">insurers and plan sponsors may have an understandably pragmatic reason to start providing coverage of Wegovy: while covering even some of the costs may seem imposing, the considerable outlay could be offset by the savings realized from reduced spending on long-term medical care relating to obesity and heart disease.</span></span></span></span></span></span></span></span></span></p> <p><span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.25pt">Stay tuned. </span></span></span></span></span></span></p> 1319The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Planshttps://www.phiagroup.com/Media/Posts/PostId/1317/the-indirect-but-significant-impact-of-a-recent-massive-healthcare-breach-on-benefit-plansBlog,Health InsuranceMon, 11 Mar 2024 19:06:24 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Andrew Silverio, Esq. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”  </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">At stake were over 14 billion yearly transactions and this attack has seriously disrupted provider billing, interfering with patient care, and even preventing some providers from paying their employees. On top of that, a massive amount of patient information, protected under HIPAA, has been compromised. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Most of the focus among news outlets has been on the impact to providers, which is of course enormous. Those using the affected claim systems have essentially no way to be paid for their services, and many have seen cash flow come to a prompt and complete halt. The government has advised Medicare plans and related entities to relax prior authorization and timely filing requirements and the entity involved has announced a program to actually offer loans to affected providers.  However, those of us in self-funding know that it’s no simple matter to simply waive requirements like prior authorization and timely filing limits, and we have heard no word from stop-loss carriers on what action it will take if plans provide some allowances to safeguard patient care.  Plans are still able to enforce timely filing limits and other plan terms, but most don’t want to leave patients in the lurch with unpaid claims due to system disruptions entirely outside their control.  A plan that chooses to accept a late claim or waive a preauthorization requirement will be at real risk, since the stop-loss carrier is always free to enforce the terms of the plan, and its own policy, strictly and as-written.  </span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The industry is still scrambling to get the system “working” again and establish something resembling a normal claim submission pipeline and cash flow.  But once the dust settles, we would expect in the coming months to see some regulatory relief for plans and providers alike, to account for concessions and audibles that had to be made to keep the ship afloat. Looking ahead, hopefully precautionary systemic measures can be taken to account for future incidents. After all, healthcare and technology promise to be forever intertwined and there’s no telling when the next cybersecurity breach will rock the industry as it did last month. </span></span></span></span></p> 1317How the Recent Industry Cyberattack Impacts Youhttps://www.phiagroup.com/Media/Posts/PostId/1315/how-the-recent-industry-cyberattack-impacts-youBlog,Health Insurance,HIPAAThu, 07 Mar 2024 15:09:26 GMT<p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Late last month, an apparent massive cybersecurity incident involving the potential theft of patient data – this could entail personally identifiable information, sensitive health information, and financial information -- and encrypted company files seemingly paralyzed one of the nation’s largest pipelines for healthcare payments and prior authorization processing. Impacting a substantial percent of Americans’ medical claims (billions of claims totaling over a trillion dollars per year), millions have been affected. But perhaps the worst part is that many don’t even know it – and won’t be aware until they need to visit their physician or refill a prescription and face new hurdles in getting their customary treatment. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Just this week, The Washington Post published stories of patients getting billed hundreds of dollars for prescriptions that had normally been fully covered by insurance. Meanwhile, others cannot get their prescriptions filled at all no matter how much they are willing to pay and still others have found that discount coupons are no longer effective (this can literally save a person hundreds of dollars per month on a given prescription). For Americans living on airtight budgets, which is certainly a great number of our fellow countrymen, they’ve had to forego taking medications for an untold number of physical and psychiatric conditions. While it’s by no means a long-term fix, some physicians have provided their patients with sample packs of pills or offered more affordable replacement prescriptions for those needing to pay out of pocket. But we all know this band-aid solution will only go so far. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As this horrific situation has been playing out across pharmacies throughout our country, physicians in both massive hospital networks and small clinics are struggling to obtain prior authorization for exams, medications, and procedures; subsequently, many patients have faced significant delays in receiving life-altering and/or life-prolonging medical care. Such delays have also been exacerbated by the unfortunate reality that some hospitals and medical providers have not received payments and thus lack the wherewithal to keep their employees. As it is, many medical practices throughout America do not carry significant cash reserves and entirely depend on healthy cash flow to execute claim submission and payment on a timely basis as well as keep up with payroll. For facilities that administer the most expensive services (i.e., chemotherapy and other forms of cancer drugs), burning through cash reserves can mean being unable to treat patients in dire need.  </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Simply put, the residual effects of this historically monumental data breach are endless – and, for many of the most vulnerable Americans who are already living on the margins of society, there appears to be no end in sight to physicians and hospitals not receiving adequate funding from private insurers, Medicare, and Medicaid. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As Molly Fulton, the chief operating officer of Arlington Urgent Care, a chain of urgent care centers around Columbus, Ohio, that’s currently carrying over $650,000 in unpaid insurance reimbursements, told the New York Times, “This is worse than when Covid hit because even though we didn’t get paid for a while then either, at least we knew there was going to be a fix. Here, there is just no end in sight.”</span></span></span></span></span></span></p> 1315Welcome to the Subrogation Spherehttps://www.phiagroup.com/Media/Posts/PostId/1310/welcome-to-the-subrogation-sphereBlog,Health Insurance,Healthcare Costs,SubrogationFri, 09 Feb 2024 14:43:40 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">By: Cindy Merrell, Esq. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The Subrogation Sphere Is a Place Where Opponents Become Allies  </span></span></b></span></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Las Vegas does not have the only sphere that can provide an extraordinary experience for its participants. Let me introduce you to the subrogation sphere where participants may first appear to have conflicting interests but can become allies. When a health plan member is injured because of a third-party action it sets into motion a dance involving many players, potentially including the plan participant, at-fault party, medical providers, stop loss carrier, and the health plan. Each player is trying to determine which player is the proper payor of the plan participant’s medical expenses. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The Alliance Begins </span></span></b></span></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">My primary duty as a subrogation attorney is to identify the proper payor of the health plan participant’s medical expenses. To successfully perform my job, I have regular contact with attorneys for both stop loss carriers, facilities, and plan participants’ attorneys. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Just the other week, one of our third-party administrator clients reached out to us because they were having difficulty getting a group’s stop loss carrier to process a $500,000.00 trauma bill. When we took a deep dive into the facts, we found out the member had been involved in a motor vehicle wreck caused by a third party. In this case, the auto policy limits were minimal. The hospital lien and health plan reimbursement amount far exceeded the available auto policy limits. Given the size of the trauma bill, the hospital retained an attorney to pursue their interest. The injured plan participant retained an attorney. The general counsel for the stop loss carrier was involved and The Phia Group was pursuing the subrogation/reimbursement interest on behalf of the health plan. Everyone was at a stalemate. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">I knew that no one could “win” on this case. The plan participant was stressing over the $500,000.00 unpaid trauma bill. The self-funded health plan employer group was stressing over the same bill, not only because their valued employee was stressed and injured, but because this large of a claim without the stop loss reimbursement could be financially catastrophic to the health plan. The plan participant’s attorney could not resolve the plan participant’s claim against the auto carrier given the size of the provider lien and the health plan’s reimbursement interest. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">No One Wins, but Everyone Wins</span></span></b></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">When I talked to the plan participant’s attorney, I could hear the desperation in his voice as he simply did not know what to do. His client who had suffered a catastrophic injury was more worried about the large trauma bill than his own recovery. I asked the plan participant’s attorney if his client would consider entering into a pre-settlement agreement in which the health plan and the plan participant could both get at least some portion of the minimal limits. After the plan participant agreed to my proposal, I had to get the stop loss carrier on board. I quickly realized the stop loss carrier simply did not have all the facts and I was able to provide the missing information and get the trauma bill processed. Once the trauma bill was processed and paid, the hospital lien was withdrawn. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Why Does the Alliance Matter? </span></span></b></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The subrogation sphere can provide a meaningful impact for many people. In my example, the plan participant did not face the financial hardship of a $500,000.00 trauma bill. The hospital that provided the medical care received compensation for the services it provided. Finally, the health plan could remain self-funded. The health plan’s self-funded status allows its employees and their dependents to have comprehensive health care with lower premiums.</span></span></span></span></p> 1310Are Measles Making a Comeback?https://www.phiagroup.com/Media/Posts/PostId/1308/are-measles-making-a-comebackBlog,Health Insurance,Healthcare CostsWed, 31 Jan 2024 14:52:22 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">When Dr. Michael Osterholm speaks, people listen – even if many do so begrudgingly. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">The ever-serious epidemiologist out of Minnesota, who forewarned of a global pandemic years ago and has garnered the not-so-flattering nickname “Bad News Mike,” has a new dire message about the recent measles outbreak, one to which children are most susceptible, that has started to trickle through pockets of Europe and, more recently, the US:</span></span></span></span></span></span></span></p> <p class="gntarbp" style="margin: 10.5pt 0in; text-align: justify;"><span style="font-size:12pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="color:black">“We're going to start seeing more and more of these outbreaks,” Osterholm told <i>USA TODAY</i> last month. “We're going to see more kids seriously ill, hospitalized and even die. And what's so tragic about this, these are all preventable.”</span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">In late January, the World Health Organization (WHO) reported that measles cases spiked more than 40-fold in 2023 compared with 2022. Approximately 30 percent of those cases were in Kazakhstan, where there is an exceptionally high number of children who aren’t vaccinated. In England, there were 250 confirmed measles cases, most impacting children younger than ten. Although last year in the US, the number of measles cases reported was lower compared to most pre-COVID years, there have been ominous signs of trouble: Philadelphia has thus far recorded nine cases of measles, Washington State has identified three cases and investigated three others, while several other states have been tracing contacts of a single case. From a global perspective, 49 countries are experiencing what the WHO calls “large or disruptive outbreaks.”</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">As Osterholms noted, an uptick in severe illnesses, hospitalizations, and even deaths will follow. Per the Centers for Disease Control and Prevention (CDC), approximately a fifth of those who contract measles will be hospitalized due to a range of issues including uncontrollable diarrhea, dehydration, fever, conjunctivitis, skin rash, pneumonia triggering long-term respiratory issues, and possibly even brain inflammation sparking neurological issues. More alarmingly, it is estimated that out of every thousand children who come down with measles, one to three will inevitably die. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">But, most maddeningly, as Osterholm also referenced, the vast majority of recent measles cases, which are incredibly contagious as the virus can drift in the air for a couple hours, could have been prevented. A single dose of the measles vaccine is 93 percent effective at stopping the virus, according to the CDC. For that reason alone, nearly every single parent alive has their children vaccinated (in the US, the measles vaccine is given twice, at 12-15 months old and then again at 4-6 years of age); but there’s always a small minority that doesn’t – and that is precisely what appears to be the root cause of the current problem. Generally speaking, for measles to remain in check, at least 95 percent of a given population needs to be immunized; in Europe, the percentage of people who had received a first dose dipped from 96 percent in 2019 to 93 percent in 2022. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">“We actually knew this was going to happen, so it’s not news for us,” Dr. Natasha Crowcroft told the <i>New York Times</i> in regard to Europe’s current rise in measles cases. “There are times when there’s absolutely no pleasure in being right, and this is one of those.” </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">In terms of the aforementioned stateside cases, <span style="background:white">most unsurprisingly involved young children and adolescents who didn’t receive the measles, mumps and rubella (MMR) vaccine, despite being eligible. (Undoubtedly, </span><span style="background:#fcfcfc">measles is far from the only vaccine-preventable disease that looms as a major public health threat; other such diseases include polio, mumps, diphtheria, tetanus, whooping cough, and hepatitis B.)</span><span style="background:white"> But it is important to note that the rising number of unvaccinated children may not solely be attributed to an increasing body of parents reluctant to comply with vaccine recommendations for their children – a problem that only becomes magnified when their children have returned from international travel. Another chief culprit may be the larger, socioeconomic force in play: the unfortunate reality that broad swaths of the American population, naturally those uninsured and living below the Federal Poverty Level, (never mind millions living in impoverished communities around the globe) simply don’t have access to proper healthcare, a dynamic more broadly known as health inequity. Even more so, it has been well documented that childhood vaccination rates have been on the decline in America since the onset of COVID, further broadening pre-existing gaps in vaccine participation. </span></span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">This unjust situation speaks to many issues, not least of which is that health insurance remains prohibitively expensive for many Americans who are unemployed, self-employed, employed by companies that provide substandard coverage, or ineligible for Medicare and/or Medicaid. While immunizations, including those for measles, are considered preventive care and thus covered without cost-sharing under private health plans, millions of tax-paying Americans remain without adequate access to such plans. When will that change for the betterment of society?</span></span></span></span></span></p> 1308A New Year Brings New (Higher) Prescription Drug Priceshttps://www.phiagroup.com/Media/Posts/PostId/1306/a-new-year-brings-new-higher-prescription-drug-pricesBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 18 Jan 2024 15:32:49 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">It must be January. W-2 forms are hitting the mail. Fitness centers are packed to the brim. The NFL playoffs are in full force. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">And, yes, pharmaceutical companies are hiking prices on their drugs. This time of year,<span style="background:white"><span style="color:black"><span style="letter-spacing:.3pt"> when insurance plans turnover,</span></span></span> Big Pharma unveils its list of new (aka elevated) prices for drugs, which, particularly concerning newly launched ones, sparks sticker shock for consumers. Certainly, January 2024 does not appear to be an exception to this unpleasant trend. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">On December 29 -- as many were making last-minute New Year’s Eve plans – the unsettling news dropped: globally recognized drugmakers, including Pfizer, Sanofi, and Takeda Pharmaceutical (all multibillion-dollar, publicly traded companies), were gearing up for price hikes on <i>over 500</i> drugs, including over 140 different brands of drugs. For the second consecutive year, Pfizer declared the most price hikes in January as the New York-based drugmaker is responsible for more than a quarter of all the drugs with anticipated price hikes. Meanwhile, Takeda-owned Baxalta released the second-highest number of price increases, with 53 hikes planned thus far, and Sanofi plans to elevate prices on its typhoid fever, rabies and yellow fever vaccines each by 9% this month. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Why the markup for an exceptionally large number of medications this year? The expected culprits – lingering high inflation and supply chain backups, largely stemming from a drawn-out Middle East Conflict – account for some, but certainly not all, of the issues. At this moment in time, there are also notable political forces at play, namely Big Pharma bracing for the profound impact of healthcare cost reduction measures in President Biden’s <span style="background:white"><span style="color:black">Inflation Reduction Act (IRA) coming into effect. (This past August, the U.S. Department of Health and Human Services (HHS) publicly released the first ten drugs covered under Medicare Part D for negotiation; the negotiated prices will become effective beginning in 2026.) Not to oversimplify the matter, but Big Pharma is essentially anticipating lost revenue in the not-so-distant future and it feels it needs to compensate for the shortfall somehow, hence the hefty volume of upticks this month. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In other words, in the coming weeks, millions of Americans, many of whom are of advanced age and living below the federal poverty level, will be walking up to their local pharmacy counter to pay for their respective medications and learn that their co-pays and/or out-of-pocket expenses have gone up at least moderately, and in some cases, dramatically. And they will be faced with the gut-wrenching decision: do they fork over the extra cash for life-altering or even life-prolonging medications at the expense of cutting back on groceries and turning off the heat in single-digit temperatures? </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Of course, this conundrum does not only apply to January as throughout the calendar year, Americans grapple with such dilemmas. But it’s certainly a problem that becomes particularly acute this time of year – one that already presents considerable challenges to many people’s physical and mental health. </span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">While geopolitical events and policy decisions may be uncontrollable and unpredictable, there are cost containment techniques that employer-sponsored health plans can employ to alleviate said burden on their respective participants. There are, in fact, viable methods for lowering prescription drug costs even when the titans of the pharma industry inflate their prices. Certainly, prescription (and overall healthcare) cost containment programs are not necessarily easy to execute. They require ingenuity, extensive data benchmarking, and widespread participant engagement. But they do represent one effective means for countering what continues to be a dreaded January tradition: a surge in prescription drug prices across the board.</span></span></span></p> 1306Considerations Regarding the Exclusion of Gender-Affirming Carehttps://www.phiagroup.com/Media/Posts/PostId/1305/considerations-regarding-the-exclusion-of-gender-affirming-careBlog,Health Insurance,Healthcare Costs,PlanTue, 16 Jan 2024 20:33:52 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Kendall Jackson, Esq. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Gender-affirming care was a particularly popular topic throughout 2023. As we enter the new year, the prevalent discussion concerning plan coverage of such care will certainly continue. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">For self-funded health plans, the decision of whether to cover or exclude gender-affirming care is quite multilayered. Specifically for plans that exclude gender-affirming care within their plan documents, there are several potential discrimination concerns. An important element when evaluating these concerns is what law applies to the plan. For instance, certain state laws may not apply to a self-funded plan governed by the Employee Retirement Income Security Act (ERISA) due to ERISA preemption. ERISA preemption operates to preempt state insurance laws as they relate to employee benefit plans. Accordingly, any state laws that may require coverage or ban coverage for gender-affirming care would not apply to an ERISA plan. This is noteworthy as ERISA affords an employer the broad discretion to construct and design the coverage and benefits for its employees. As there is no federal requirement for plans to cover gender-affirming care, an ERISA plan may choose to cover or exclude benefits for gender-affirming care. Alternatively, non-ERISA plans, such as self-funded church plans or non-federal governmental plans, have slightly less flexibility and must adhere to both state and federal law. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Federal protections against discrimination have been, and will continue to be, integral to filling the gaps in health coverage for marginalized groups. Consequently, the potential compliance concerns outlined below apply particularly to plans that elect to exclude gender-affirming care. The first consideration is whether the plan is subject to Section 1557 of the Affordable Care Act (ACA), which hinges on whether the plan sponsor receives any federal financial assistance through the Department of Health and Human Services (HHS). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability. HHS provided guidance in a notice in March 2022 that clarified the extent of Section 1557’s protections.<a href="#_ftn1" name="_ftnref1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS opined that Section 1557’s protection against sex discrimination encompassed an individual’s right to access health programs that are free from discrimination based on gender identity. HHS stated that a plan categorically excluding benefits due to an individual’s gender identity was discrimination and prohibited by Section 1557. At the time, this guidance had a significant impact because if a plan was subject to Section 1557, generally, any exclusion of benefits or services related to, for example, transgender care, would be deemed a categorical exclusion and would be prohibited. Although HHS’s viewpoint was contested, nevertheless, it demonstrates the movement to protect against the exclusion of benefits based on gender identity. Accordingly, to avoid allegations of discrimination, self-funded plans subject to Section 1557 should consider removing gender-affirming care exclusions.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:105%"><span style="font-family:"Calibri",sans-serif">Even if a plan is not subject to ACA Section 1557, there are still significant discrimination concerns for plans with gender-affirming care exclusions if they create a disparity in coverage for certain individuals. These concerns stem from scrutiny from the Equal Employment Opportunity Commission and the protection against discrimination based on gender identity under Title VII of the Civil Rights Act of 1964. There have been several lawsuits brought forth by transgender individuals under these laws and Section 1557 about gender-affirming care exclusions, and courts have ruled in their favor on some occasions. An example of an exclusion that could create a disparity in coverage is a sex reassignment exclusion. In this case, while it does not exclude care for transgender individuals specifically, it is possible it could be viewed as discriminatory because it functions to categorically exclude services which will overwhelmingly be needed only by transgender individuals. As a result, while self-funded health plans are not mandated to cover gender-affirming care, the compliant approach with regard to all applicable laws would be to remove exclusions for gender-affirming care from the plan. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Pivoting to a different perspective, for self-funded non-ERISA plans subject to state law, there have been many changes surrounding gender-affirming care over the past year. For example, in Texas, on September 1, 2023, a<a name="_Hlk155366211"> law</a> banning gender-affirming care, such as treatments for gender dysphoria, transitioning, and reassignment for minors took effect. The law prohibits health plans from covering services “that are intended to transition a child’s biological sex as determined by the child’s sex organs, chromosomes, and endogenous profiles.”<a href="#_ftn2" name="_ftnref2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> In Ohio, governor Mike DeWine signed an executive order on January 5, 2024, that banned hospitals and ambulatory surgical facilities from performing gender-affirming surgeries on minors.<a href="#_ftn3" name="_ftnref3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> In New Hampshire, the New Hampshire House recently passed a bill that will now be sent to the New Hampshire Senate. This bill proposes to ban gender-affirming procedures for minors.<a href="#_ftn4" name="_ftnref4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> The bill also proposes to prohibit health care workers from referring minors to out-of-state facilities that may perform gender-affirming procedures. These are only a few examples of the recent developments in state legislation that concern gender-affirming care. As of November 2023, 22 states had a law or policy banning gender-affirming care.<a href="#_ftn5" name="_ftnref5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> There will likely be more development in state legislation in the new year and plans subject to state law should be mindful of how these laws and policies may influence their plan structure.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The decision of whether to cover or exclude gender-affirming care is a multilayered matter and will likely depend on the intent of the employer. There are varying considerations depending on the type of plan and applicable law. As the landscape is constantly changing in regard to gender-affirming care laws, it is essential that plans consider plan document compliance, the potential for discrimination allegations, and, if applicable, what is mandated or banned by relevant states. </span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <div>  <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref1" name="_ftn1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and</span></span></p> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif">Patient Privacy, https://www.hhs.gov/sites/default/files/hhs-ocr-notice-and-guidance-gender-affirming-care.pdf</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref2" name="_ftn2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> Senate Bill 14, https://capitol.texas.gov/tlodocs/88R/billtext/html/SB00014I.htm</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref3" name="_ftn3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> Ohio Gov. DeWine signs executive order banning hospitals from gender transition surgeries on minors, https://ohiocapitaljournal.com/2024/01/05/ohio-gov-dewine-signs-executive-order-banning-hospitals-from-gender-transition-surgeries-on-minors/</span></span></p> </div> <div id="ftn4"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref4" name="_ftn4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> House Bill 619, https://gencourt.state.nh.us/bill_status/legacy/bs2016/billText.aspx?sy=2024&id=71&txtFormat=pdf&v=current</span></span></p> </div> <div id="ftn5"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref5" name="_ftn5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> HRC Foundation, https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map</span></span></p> </div> </div> 1305Is the Department of Labor Offsetting a Major Problem?https://www.phiagroup.com/Media/Posts/PostId/1300/is-the-department-of-labor-offsetting-a-major-problemBlog,Affordable Care Act,Cost Containment,Health Insurance,Healthcare Costs,Healthcare Exchanges,Hospital BillsWed, 03 Jan 2024 18:05:56 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As if Americans on employer-based health plans didn’t face enough obstacles in trying to obtain reasonably priced healthcare. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The inconvenient truth is that many participants on ERISA self-funded health plans, ones who are often already paying high premiums and deductibles, have unknowingly fallen victim to the ethically questionable – although not technically outlawed -- practice of cross-plan offsetting over the years. In fact, only very recently, as in the past several months, has there been heightened awareness of the adverse effects of cross-plan offsetting on unsuspecting American plan participants. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">First, a quick primer on cross-plan offsetting: </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">There are times when a given health plan erroneously overpays a provider for a service rendered. Perhaps because of a human or AI-induced oversight or timing snafu or minor typo, the plan will pay the full charge when it should have paid the claim based on the (lower) usual and customary or maximum allowable charge, per the plan document. Whatever the source of the erroneous payment might have been, the provider now has the extra funds (this could be thousands of dollars) and, by law, does not have to refund the plan. And they almost never do. It sounds like an inequitable practice, but, as long as the provider did not receive more than the billed charges, it’s entirely legal. Plans have<span style="background:white"><span style="color:#212121"> no legal recourse and are often left with no choice but to close the file. </span></span> </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Naturally, the plan’s respective TPA that administered the claim feels that the provider owes it money. In some cases, said TPA tries to recoup the excess funds by not<i> </i>paying that same provider the full amount due for a plan participant’s claim on <i>another</i> one of its plans. Yes, this is a blatant breach of their fiduciary duties. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">But most importantly, the end result is that the participant on this second plan, through no fault of their own, will see their claim denied by reading a cryptically written note on their explanation of benefits; the TPA is trying to exact revenge on the provider, but it is the hard-working, often cash-strapped participant – one with zero knowledge of the overpayment backstory -- who gets shortchanged by either getting balance billed for the erroneously offset claims or having to pay a hefty out-of-pocket amount for services rendered. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Many TPAs have been engaging in cross-plan offsetting for years, but this past fall, one in particular, EmblemHealth Inc., <span style="background:white"><span style="color:black">a New York-based insurer and TPA of ERISA group health plans,</span></span> was caught red-handed and made an example of for all the world to see. On September 29, the Department of Labor (DOL) <span style="background:white"><span style="color:black">entered into a settlement agreement with EmblemHealth Inc., resolving claims that the company violated its fiduciary duties under federal law by engaging in cross-plan offsetting to recover alleged overpayments. The DOL’s </span></span><span style="background:white"><span style="color:#212121">Employee Benefits Security Administration</span></span><span style="background:white"><span style="color:black"> (EBSA) submitted that Emblem benefitted by wrongfully keeping money from one health plan for a debt owed by another health plan.</span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">So, what were the repercussions for Emblem? Per the terms of the settlement, Emblem pledged to no longer practice cross-plan offsetting and modify its policies, procedures, and practices accordingly no later than January 1, 2024, or as soon as reasonably possible for insured plans prospectively. That the DOL essentially gave Emblem a three-month deadline is noteworthy. Traditionally, the DOL is known for working at a glacial pace in adjudicating matters. But not this time, not when a stern dictum is in order to TPAs across the country: no longer can they get away with committing </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#212121">blatant violations of ERISA by using one plan’s money to take care of another’s debt under the guise of (arbitrarily) denying claims. Meanwhile, regarding </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">retrospective corrective actions dating back to July 16, 2015, Emblem has been mandated to reimburse present and past participants and dependents whose reimbursements were reduced via cross-plan offsetting. Should Emblem not abide by the terms of this agreement, the DOL could very well take the TPA back to court.</span></span></span></span></span> </span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">To be clear, an untold number of other TPAs have long engaged in this practice, some possibly unaware of the legal issues caused by it. Clearly, the DOL has stepped up enforcement here and it will be interesting to see whether cross-plan offsetting continues to be a fairly commonplace practice now that Emblem has been put on notice.</span></span></span></span></span></p> 1300Time’s Up! It’s Gag Clause Attestation Seasonhttps://www.phiagroup.com/Media/Posts/PostId/1299/times-up-its-gag-clause-attestation-seasonBlog,Health Insurance,Healthcare Costs,Third Party AdministratorsTue, 26 Dec 2023 21:54:36 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Andrew Silverio, Esq.<br /> <br /> As the year wraps up and plans and TPAs around the country are scrambling to handle renewals, another challenge looms large in 2023 – the first annual gag clause attestation.  As a reminder, the Consolidated Appropriations Act, 2021 (CAA) prohibits plans from entering into any contracts with providers and certain other entities that contain “gag clauses” – and requires them to attest annually that their contracts are free of them. The first attestation is due at the end of 2023, and it will cover the period of December 27, 2021 through December 31, 2023. The goal of the legislation is transparency, but it has glaring holes – contracts can’t prohibit plans from sharing certain information with other entities, but nothing requires them to be granted access to this information in the first place.<br /> <br /> While payers have technically been on notice of this requirement since the CAA passed, we all know how things get put off, and we saw a furious uptick of questions and activity surrounding this requirement in the second half of 2023. Unfortunately, it’s because of the nature of how the industry and its contracts have developed over the years that it’s more likely to find gag clauses than not to – especially in network and pharmacy benefit agreements.  Unfortunately, many plans have been put in an unfortunate position by many big players – we won’t name names – who have simply issued broad statements that their contracts do not contain gag clauses (statements that are often proven false with a simple review of the actual agreements) and refused to entertain changes or even sometimes let plans review the contracts directly.  Plans in this situation face a difficult choice: submit an attestation knowing that these representations are questionable at best and that the compliance obligation ultimately falls on them, or fail to submit the attestation, risking whatever enforcement action might follow.  It’s not entirely clear how enforcement will play out, but penalties for failure to attest <i>could</i> come in the form of the $100 per day excise tax under ERISA or excise tax via the IRS.<br /> <br /> Given the widespread confusion, disagreement, and outright disregard of this requirement, it’s also not clear how much effort will go into enforcement and auditing plans for compliance.  We’ve been approached by countless clients inquiring about whispers and rumors of an enforcement delay.  Everyone has heard from someone who heard from someone that enforcement will be delayed - however we’ve seen no indication from any official source that any relief is coming.  At this point it’s safe to say relief in the form of delays or waivers, if it happens at all, won’t be coming in 2023.  So at this point, all plans can do is the best they can to get their existing agreements in order, submit the required attestation, and be on the lookout for gag clauses in any new contracts moving forward.</span></span></span></p> 1299For Sickle Cell Disease Patients, Hope Has Arrived – but at What Cost?https://www.phiagroup.com/Media/Posts/PostId/1298/for-sickle-cell-disease-patients-hope-has-arrived-but-at-what-costBlog,Cost Containment,Health Insurance,Healthcare Costs,Hospital BillsThu, 21 Dec 2023 16:32:52 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:#000000;">By: Kelly E. Dempsey, Esq.</span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> For generations of sickle cell disease (SCD) patients, the suffering has been unbearable – with no end in sight. SCD, an </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif">inherited genetic red blood cell disorder that affects hemoglobin, the protein that carries oxygen throughout the body, torments nearly 100,000 Americans (20 million people worldwide), a disproportionate number of whom are African-American. Among other symptoms, SCD often triggers chronic bouts of excruciating pain that require regular hospitalization, organ failure, strokes, and shortened life expectancy. Meanwhile, the only known cure for the insidious disease has been a bone marrow transplant</span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">. </span><br /> <br /> Until last month, that is. Developments in this area are exciting for patients, but may make some waves for employers and their self-funded health plans. </span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><br /> In the middle of the invariably hectic holiday season, some above-the-fold medical news dropped when the FDA announced approval of two gene-based treatments for SCD: </span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">Casgevy, the first-ever therapy to incorporate the gene-editing technique CRISPR which enables scientists to make cuts in DNA, and Lyfgenia, grounded in an older gene therapy approach in which a virus is used to deliver a healthy copy of the gene that produces adult hemoglobin to compensate for the one producing the sickled form. Both Casgevy (produced by Vertex Pharmaceuticals and CRISPR Therapeutics) and Lyfgenia (generated by Bluebird Bio) have been cleared for patients 12 and older and are designed to serve as a one-time panacea. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> Certainly, for those with sickle cell who have long felt they have been suffering in silence, the disease now being the focus of this dramatic new approach to therapy development is cause for celebration. In reality, the majority of sickle cell patients can’t find a matching bone marrow donor, so this scientific breakthrough could truly be life-changing for the masses dealing with the agonizing blood disorder. And the early signs are, in fact, promising: through rounds of clinical trials, Casgevy and Lyfgenia have proved to be so effective as one-time treatments that they have been widely considered to be “cures” by the scientific community. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> But, like any cutting-edge therapy, these won’t be cheap. Consider that Casgevy will cost <i>$2.2 million</i> for the one-time treatment while Lyfgenia will cost <i>$3.1 million</i>. It also bears mentioning that these multimillion-dollar treatments will need to be administered in a monthslong process within large-scale medical systems that can perform stem cell transplants – systems that are inaccessible to millions of impoverished Americans living in states that have not broadened their Medicaid programs. The global picture is even bleaker. A recent <i>New York Times</i> story indicated that Vertex has been focusing on gaining approval in six wealthy nations – U.S., Italy, Britain, France, Germany, and Saudi Arabia – that represent merely 2 percent of the worldwide sickle cell population. Meanwhile, approximately 75 percent of the planet’s sickle cell patients reside in sub-Saharan Africa, where basic medical resources can often be scarce, to put it mildly. It should be noted that not all sickle cell patients have cases severe enough to warrant the new therapies; for reference, roughly only 20,000 in the US are believed to be sick enough to qualify for treatment. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> But back to the daunting financial numbers. Why are the price tags so ridiculously expensive? Those pursuing Casgevy and Lyfgenia will need to have their cells harvested and transported to a lab for manufacturing; undergo multiple rounds of rigorous chemotherapy, which very well can pose its own risks; and be hospitalized for months on end. As Vertex’s chief scientific officer, Dr. David Altshuler, was quoted as saying in the previously mentioned <i>New York Times</i> article, “</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="color:#000000;">A medicine that is so resource-intensive as this is may not be appropriate in many places where the amount of resources for health care is more limited.” </span><span style="color:#363636"></span><br /> <span style="color:#000000;"><br /> For employer-sponsored health plans, the multi-million-dollar question is whether they will have the resources to foot the bill. Will most plans simply be inclined to outright exclude this therapy? Will these new treatments be the most cost-effective method for providing services to those with sickle cell disease?  For those plans that do provide coverage, how will their respective stop-loss policies be impacted? What sort of coverage, if any, will be provided by Medicaid and/or Medicare?  </span><span style="color:#363636"></span><br /> <span style="color:black"><span style="letter-spacing:.3pt"></span></span><br /> <span style="color:#000000;"><span style="letter-spacing:.3pt">Gene therapy and cellular therapy have been hot topics in the last year, as well as the ever-increasing price tag on medical care and new treatments. It reminds me of the meme floating around social media about Kevin McCallister’s grocery list from <i>Home Alone</i>. In 1990 he purchased a half-gallon of milk, a half-gallon of orange juice, a TV dinner, bread, frozen mac and cheese, laundry detergent, cling wrap, toilet paper, a pack of army men, and dryer sheets all for $19.83. In 2022, that same grocery list cost $44.40 and in 2023 it’s now up to $72.28 … My intent was to make readers laugh, but if you need tissues, I understand as well (I’ll see if Matt has any Phia logo tissues on hand). <br /> <br /> Stay tuned. </span></span><span style="color:black"><span style="letter-spacing:.3pt"></span></span></span></span></span></span></span></span></p> 1298Is Artificial Intelligence the New Frontier for Healthcare?https://www.phiagroup.com/Media/Posts/PostId/1294/is-artificial-intelligence-the-new-frontier-for-healthcareBlog,Health Insurance,Healthcare CostsTue, 12 Dec 2023 19:13:59 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky<br /> <br /> The ills of the American healthcare system, namely an undue administrative burden on healthcare providers and a <span style="background:#fcfcfc">labor supply not keeping pace with the demand for services</span>, have been well documented. But now, as we grind through the 2020s, relief may be on the way with the booming popularity (or in some cases, acceptance) of artificial intelligence (AI). Many healthcare experts believe that AI – a mechanism grounded in the simulation of human intelligence by computerized systems and one that has already changed how many humans learn and work – could revolutionize the field. But as enticing as the prospect of AI driving forward greater industrywide systemic efficiency may be, should this gargantuan development be universally celebrated? <br /> <br /> Certainly, from a patient's perspective, AI has intriguing potential. Imagine not having to wait on hold for who knows how long to schedule your next medical appointment because instead you could simply connect with <span style="background:#fcfcfc">Generative AI that spews out language so natural and fluid that it seemingly emanates from a person’s voice box? The same holds true with medication refills and answers to straightforward medical inquiries. For tens of millions of Americans, including those for whom the day is not long enough to string together multiple low-paying jobs, the saved time could be, for lack of a better word, life-altering. Meanwhile, for an often burned-out, short-staffed medical workforce trying to allocate scarce resources, this could be a tremendous boon. And for their respective patients suffering from both acute and chronic conditions, the end result could be vastly higher quality, more customized care. </span></span></span><br /> <span style="background:#fcfcfc"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> The titans of the industry have certainly taken note over the past year plus. In a recent article published on the Johnson & Johnson website, </span></span></span></span><span style="font-size:12.0pt"><span style="background:#f4f3f1"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Jeff Headd, Vice President, Commercial Data Science, Janssen North America Business Technology, was quoted as saying, “The rapid growth in available healthcare-related data in recent years allows us to ask bigger questions. Using the latest innovations in AI and machine learning (ML), we are able to quickly analyze these vast datasets (including electronic medical records, lab results or even medical imaging like X-rays, MRIs and CT scans), uncover new insights and then drive actions with real potential to improve patient outcomes.”<br /> <br /> Bear in mind this could very well mean improving the welfare of some of America’s most historically underserved populations in healthcare – African Americans, Latinos, and American Indians and Alaska Natives. Perhaps another segment of the population that stands to be a chief beneficiary are communities residing in the country’s most rural outposts. Simply put, if medical practitioners are able to leverage AI toward streamlining time-consuming functions (i.e., administrative work), there will be more opportunities to interact with broader swaths of the population. </span></span></span></span></span></span></span></span><br /> <span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:#fcfcfc"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> And yet, despite all of society’s collective wonderment, the potential drawbacks of AI taking over healthcare warrant consideration, too. Speaking of healthcare-related data, as Headd referenced, would the expected airtight protection of patients’ personal data ever be compromised with AI assuming a more prominent role? With </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">more healthcare software systems adopting AI-based features, there is greater need for gathering more data, naturally increasing the likelihood of security threats and violations of compliance with regulatory frameworks such as  </span></span></span></span></span><a href="https://logrhythm.com/solutions/compliance/hipaa/" style="color:blue; text-decoration:underline" target="_blank"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="text-decoration:none">Health Insurance Portability and Accountability Act of 1996 (HIPAA)</span></span></span></span></span></span></a><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">.<span style="background:white"> (As of this hour HIPAA does not have a specific provision that relates to AI.) What does this mean for the common folk? While the hypothetical answer could be a blog in and of itself, the safeguarding of protected health information (“PHI”), which can involve anything from one’s cholesterol levels to mental health history, could be in jeopardy. Lest we forget, AI is both <i>really</i> new and extremely powerful, meaning the unanticipated side effects are boundless. Just like personal financial information, PHI is not something that should be floating aimlessly around the virtual universe.</span></span></span></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> Nevertheless, there’s a reason that industries across all seven continents have incorporated artificial intelligence into their systems over the past couple years. Specifically concerning the medical field, what provider wouldn’t welcome enhanced efficiency and productivity and more expedited decision-making? What patient wouldn’t like to know that their physicians are making better use of their precious time? By all accounts, AI is not going anywhere – in the healthcare industry and beyond. But still, it doesn’t hurt to consume the latest (i.e., daily) news of artificial intelligence with a (no pun intended) healthy dose of skepticism.</span></span></span></span></p> 1294Being Mindful of Telemedicine Accesshttps://www.phiagroup.com/Media/Posts/PostId/1288/being-mindful-of-telemedicine-accessBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 09 Nov 2023 15:01:53 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By Jen McCormick, Esq. and David Ostrowsky<br /> <br /> From a healthcare standpoint, two of the most significant byproducts of the COVID-19 pandemic have been the exploding popularity of Telemedicine, </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">the practice of providing medical <i>and</i> mental health services remotely, and a heightened awareness of many Americans’ longstanding mental health issues. Due to a confluence of prolonged extenuating circumstances, it became readily apparent to healthcare providers, politicians, social workers, employers, teachers, and parents on both sides of the Mississippi that a.) the inimitable convenience of virtual healthcare does not compromise quality (at least for some patients and practitioners) and b.) many Americans experiencing emotional distress have long been suffering in silence.<br /> <br /> Why should these two developments that came to light during the dark days of the pandemic be mutually exclusive?<br /> <br /> Certainly, many health plans realize that the inherent advantages of Telemedicine (namely, ease of access and time efficiency) have motivated otherwise hesitant patients to seek mental healthcare support. Telemedicine, being such a convenient and effective alternative to traditional in-person care, has helped meet the unprecedented demand for mental health services. For many coping with severe mental health issues, an appropriate facility is not easily accessible via public transportation or even a car – a conundrum that is only exacerbated when one is juggling multiple low-paying jobs and scrounging for childcare. And yet, some health plans – ones that purportedly provide robust mental health coverage -- are inclined to provide Telemedicine services solely for patients suffering from physical ailments. Others were providing Telemedicine for both physical health and mental health/substance use disorder services when social distancing was in vogue during the pandemic, but have since precluded the latter amidst the return to relative normalcy. Ethics aside, this ultimately may be a potential violation of the </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Mental Health Parity and Addiction Equity Act (MHPAEA), which requires health plans that offer mental health and substance use disorder benefits to do so in parity with medical and surgical benefits. For the health plan, the monetary penalties could be steep, the long-term ramifications dire.<br /> <br /> Back to ethics. If someone who develops a severe skin rash on their abdomen has the ability to consult with a physician over their smartphone, why shouldn’t a participant on the very same health plan be able to consult with a mental healthcare provider about their uncontrollable OCD symptoms or worsening depression in the same (virtual) manner? Why should more stringent restrictions apply to those suffering from brain-related issues than to those dealing with tendinitis? Why should a plan participant enduring intense panic attacks – who’s paying the same premiums as everyone else on the plan – have to battle traffic and miss work to receive potentially life-changing treatment when those dealing with physical issues don’t have to be so inconvenienced? As if the stigma of requiring mental healthcare hasn’t been ingrained fully enough in the fabric of American society. By any measure, it's a grossly inequitable disparity and one that employer-sponsored health plans, particularly those subject to Nonquantitative Treatment Limitations (NQTL) requirements, would do well to strongly consider the draconian nature of.<br /> <br /> Thankfully, a new calendar year is right around the corner, meaning plan administrators and sponsors and employers still have time to review their respective plan documents and summary plan descriptions and make corresponding adjustments for lingering Telemedicine coverage discrepancies. Meanwhile, as Telemedicine regulations continue to evolve (lest we forget, this is still a fairly novel mechanism), there is even greater need for weighing potential changes to plan design as a means of ensuring MHPAEA compliance.</span></span></span></span></span></span><br /> <span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> Most importantly, America’s mental health crisis is not dissipating anytime soon, a reality of which the Department of Labor, in its compliance enforcement efforts, is well aware. </span></span></span></p> 1288Update on the Federal IDR Processhttps://www.phiagroup.com/Media/Posts/PostId/1286/update-on-the-federal-idr-processBlog,Health Insurance,Healthcare CostsFri, 27 Oct 2023 14:58:32 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Kendall Jackson, Esq.</span></span></span></span></span><br /> <span style="line-height:normal"><span style="text-autospace:none"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><br /> Recently there has been significant discussion about the federal IDR process. The IDR process is an important tool of the No Surprises Act (“NSA”) as it resolves claims for payment for out-of-network items and services. It not only provides a procedure for settling disputed claims but is also an integral mechanism for supporting the NSA’s protection for plan members against potentially crippling expenses from balance billing for high-cost out-of-network claims.<br /> <br /> In<i> Texas Medical Association v. United States Department of Health and Human Services, </i>Case No. 6:23-cv-59-JDK<i> </i>(<i>TMA IV</i>)<i>, </i>the U.S. District Court for the Eastern District of Texas<i> </i>vacated several provisions of the NSA—specifically, the batching provisions and the $350 administrative fee. In response to this decision, on August 3, 2023, the U.S. Department of Health & Human Services, the Department of Labor, and the Department of Treasury (collectively, the “Departments”) temporarily paused all federal IDR processes, including dispute initiation. On August 8, 2023, IDR entities were permitted to process batched disputes if, prior to August 3, 2023, they were already deemed eligible and administrative fees were paid. Other batched disputes that did not meet this criteria were paused.<br /> <br /> Only a few weeks later, the same court issued another opinion in <i>Texas Medical Association, et al. v. United States Department of Health and Human Services, </i>Case No. 6:22-cv-450-JDK (<i>TMA III</i>) and vacated several other provisions of the NSA, including portions of the QPA calculation methodology and the condition that a single medical air transport requires two separate IDR processes. Effective August 25, 2023, the Departments paused all federal IDR processes, including the batched disputes that were still being processed under the prior pause. Disputing parties in the open negotiations phase were permitted to continue with negotiations while all other processes were paused to allow the Departments to modify existing guidelines to comply with the court’s orders.<br /> <br /> On October 5, 2023, access to the Notice of Initiation, Selection Response, and Reselection Response webforms was restored. Access is available only for single disputes, which includes disputes submitted as a bundled item or service. Disputing parties are able to resume operations related to IDR entity selection and reselection and may also initiate new single disputes. Batched disputes, whether new or in-progress, as well as new air ambulance disputes remain paused. Parties whose IDR initiation deadline is between August 3 and November 3, 2023, will have until November 3, 2023, to initiate new single disputes. For disputes initiated between October 6 and November 3, 2023, parties will have ten business days from initiation to select a certified IDR entity. The deadline to submit fees and offers will be ten business days after the selection of the certified IDR entity. The administrative fee for new disputes is currently $50, as it reverted back to the fee that was established prior to the introduction of the $350 administrative fee in December 2022.</span></span></span></span></span></span><br /> <span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><br /> We are likely to see more established rules in response to TMA IV and TMA III in the near future. In late September, the Departments, along with the Employee Benefits Security Administration and the Centers for Medicare & Medicaid Services, collectively issued a proposed rule to address the administrative fee and the fee ranges for certified IDR entities. The proposed rule is intended to apply to disputes initiated on or after the later of the effective date of the rule or January 1, 2024. The Departments proposed an administrative fee of $150 per party per dispute, which was determined based on the costs of operating the federal IDR process. In regard to the fees for certified IDR entities, the fees are currently set by the IDR entities within a range issued annually by the Departments. The rule proposes to alter the frequency in which guidance on ranges will be provided, suggesting a shift to issuing notices more or less frequently than annually. The Departments proposed the updated ranges for disputes initiated on or after the later of the effective date of the rule or January 1, 2024, would be $200 to $840 for single determinations and $268 to $1,173 for batched disputes. Comments on the proposed rule were due by October 26, 2023. With the period recently closing, there will surely be new developments in the federal IDR process in the coming months.</span></span></span></p> 1286Empowering the 2023 SIIA National Conferencehttps://www.phiagroup.com/Media/Posts/PostId/1284/empowering-the-2023-siia-national-conferenceBlog,Health Insurance,Healthcare CostsThu, 26 Oct 2023 18:28:38 GMT<p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p class="MsoNoSpacing" style="text-align:justify; margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Earlier this month, the self-insurance industry’s most prominent thought-leaders, innovative service providers, and esteemed subject matter experts convened at the 2023 Self-Insurance Institute of America (<span style="background:white"><span style="color:black">SIIA) National Conference at the JW Marriott Phoenix Desert Ridge Resort & Spa. The SIIA National Conference,</span></span> which this year covered such pressing topics as artificial intelligence, surprise billing, emerging trends impacting the employer stop-loss market, and recent legislative and regulatory updates, <span style="background:white"><span style="color:black">is widely considered to be the self-insurance industry’s annual marquee event, bringing together hundreds of industry professionals including TPAs, vendors (</span></span>there were over 950 booths representing industry vendors stationed in the exhibitor hall)<span style="background:white"><span style="color:black">, brokers, captive managers, stop-loss carriers, and solution providers. Naturally, The Phia Group was well represented with a six-person contingent consisting of </span></span>Adam Russo, Garrick Hunt, Tim Callender, Jason Davis, Jen McCormick, and Brady Bizarro present. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In addition to meeting with clients to strategize about how to improve our partnerships going into 2024, Phia had two representatives – CEO Adam V. Russo, Esq. and Brady Bizarro, Esq., Senior Director of Legal Compliance & Regulatory Affairs – deliver one of the conference’s final presentations (“Empowering Plan Participants to Leverage Cost Containment Strategies”). The premise of Russo and Bizarro’s presentation was fairly straightforward: </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The recent trends in healthcare are cause for concern. Consider that with premiums for family health plans having increased by 54 percent in recent years, employee contributions have shot up 71 percent. Sadly, the increase in wage growth (26 percent) has not been commensurate with such drastic spikes. Put another way, tens of millions of industrious Americans, already grappling with inflation and a declining stock market, have been deprived of what they deserve – access to affordable, first-rate healthcare. Although there is no single panacea to this systemic problem bedeviling the American workforce, employers, as Russo and Bizarro reasoned, can take steps to empower their employees toward becoming engaged and knowledgeable consumers of healthcare. </span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Russo and Bizarro’s presentation had a particularly acute focus on espousing the merits of employee workshops and incentive programs to accomplish this goal. Regardless of the industry, it is often challenging to make a given employee population <i>care </i>about their healthcare spending. For many, simply being aware of paycheck deductions and out-of-pocket costs is sufficient. But what if employees learn how to access data that indicates whether they’re seeing the most capable providers? What if employees learn that a given facility they are considering for surgery is three times more expensive than an alternative one, which would translate to higher healthcare premiums? What makes these presentations even more compelling is when management, in conjunction with their respective HR department, can provide proper contextual background and empirical information – that is easily accessible in an online repository -- to elucidate the message. Rather than speaking in broad terms, offering specific examples of cost containment measures germane to the company’s make-up, health plan, and geographic location(s) can further pique participants’ interests. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Ultimately, though, for some employees, educational workshops still are not enough. They need personalized monetary incentives to be more engaged. Hence, the incentive programs that Attorneys Russo and Bizarro discussed in their presentation. In short, this is where employers may need to get creative. While there are more traditional methods for offering participants financial rewards (i.e., initiating a claim audit review program, encouraging preemptive consultation regarding medical procedures and specialty drugs), plans can customize incentive programs geared toward their employee population’s needs. For example, The Phia Group has long championed a program whereby employees (or their spouses) expecting babies will receive a $300 monthly stipend for diapers and wipes for 12 months if they choose to deliver at a facility identified as high quality, low-cost. In fact, in 2016 the <i>Boston Globe</i> ran a story on employee benefit programs (“Employers reward workers who shop around for health care”) that highlighted this unique program. This is just one example of how selecting the best provider at the best price can be a win-win for the company (as in potentially saving tens of thousands of dollars) and employee. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As seasoned experts in the healthcare cost containment industry, Attorneys Russo and Bizarro, on behalf of The Phia Group, were honored to deliver such a well-received presentation at SIIA’s biggest annual convention and look forward to enlightening the audience at next year’s conference. </span></span></span></span></span></span></p> 1284District Court Strikes a Blow to Copay Accumulator Programshttps://www.phiagroup.com/Media/Posts/PostId/1279/district-court-strikes-a-blow-to-copay-accumulator-programsBlog,Health Insurance,Healthcare Costs,Hospital BillsWed, 11 Oct 2023 15:36:22 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:">By: Andrew Silverio, Esq.<br /> <br /> Many of our clients are aware of, or even utilize, “copay accumulator” programs – these programs create plan savings by not counting amounts received by patients from manufacturer assistance programs toward annual deductibles and out-of-pocket maximums.  Some programs go a step further by actually increasing the applicable copayment for certain drugs to maximize the amount a patient may be eligible to receive from manufacturers. <br /> <br /> The Trump Administration’s Notice of Benefit and Payment Parameters for 2021 (“NBPP”) facilitated these programs by explicitly permitting plans to <i>not </i>count manufacturer assistance amounts toward annual deductibles or out of pocket maximums.  That allowed these programs to drastically increase the amounts they can redirect to plan savings – the alternative would be a program which only works until an out-of-pocket maximum is reached, which, with expensive specialty drugs, can happen in an instant.<br /> <br /> However, several patient groups brought a legal challenge against HHS and CMS, challenging the NBPP as unlawful.  On September 29 of this year, the United States District Court of the District of Columbia ruled on that challenge and sided with the Plaintiffs (see https://hivhep.org/wp-content/uploads/2023/09/HIV-Hepatitis-Policy-Institute-v.-HHS-DDC-opinion.pdf).  The Court found to be arbitrary and capricious the Trump administration’s “interpretation of the same statutory and regulatory provisions as having two different meanings, to be chosen at the discretion of regulated parties.”  Per the Court, payers cannot choose what is and is not cost-sharing paid by or on behalf of a participant – the law clearly defines that.<br /> <br /> So, for now, plans should be counting amounts received by patients from manufacturer assistance programs toward deductibles and out of pocket maximums, at least in situations where the drug is a name brand drug and there is no generic equivalent available.  The industry will need further regulations or guidance from the current administration to clarify the current state of the law and state definitively whether this practice is allowed in situations where there is a generic equivalent available. </span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: center;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span calibri="" style="font-family:"><img alt="" src="/Portals/phiagroup/images/Blog Images/Co-Pay.jpg?ver=sKiKchHKEDlhoqB2bjNX9A%3d%3d" style="width: 400px; height: 267px;" /></span></span></span></span></p> 1279The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiationshttps://www.phiagroup.com/Media/Posts/PostId/1272/the-first-ten-the-initial-round-of-drugs-subject-to-medicare-price-negotiationsBlog,Health Insurance,Healthcare Costs,MedicaidWed, 30 Aug 2023 14:36:00 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky<br /> <br /> Traditionally, August is a slow news month. Congress is on recess; dignitaries have ensconced themselves in their summer homes; many reporters are on vacation. Invariably, the waning days of summer don’t appear conducive to delivering breaking news.<br /> <br /> Not this year, however. Indeed, August 2023 will go down as a momentous period of time in American history. A month that was dominated by headlines involving criminal charges brought against former President Donald Trump ended with a healthcare development that will surely impact an untold number of Americans for the foreseeable future.<br /> <br /> On August 29, President Biden unveiled the first ten prescription drugs that will be subject to price negotiation with Medicare (<span style="background:white"><span style="color:black">Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp and NovoLog), representing a watershed moment for Democrats </span></span>who have spent years clamoring for lower prescription costs. <span style="background:white"><span style="color:black">The Medicare Drug Price Negotiation Program was a key component of the </span></span></span></span></span><a href="https://abcnews.go.com/Politics/biden-takes-victory-lap-inflation-reduction-act-amid/story?id=102319410" style="color:blue; text-decoration:underline" target="_blank"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black"><span style="text-decoration:none"><span style="text-underline:none">Inflation Reduction Act</span></span></span></span></span></span></span></a><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">, which also caps the monthly out-of-pocket cost of insulin at $35 for Medicare enrollees, enabling the U.S. government to directly negotiate with drug manufacturers for the first time in the program’s 58-year history. When the new prices for the aforementioned drugs that <span style="letter-spacing:.3pt">treat heart disease, certain cancers, diabetes, and autoimmune diseases </span>go into effect in 2026, over nine million Medicare recipients will enjoy significant cost savings. It’s worth noting that Medicare beneficiaries taking the ten drugs chosen for negotiation paid an aggregate total of $3.4 billion in out-of-pocket costs for such medications in 2022, per the Department of Health and Human Services.<br /> <br /> “For far too long, Americans have paid more for prescription drugs than any major economy,” Biden remarked in an official statement released from The White House. “And while the pharmaceutical industry makes record profits, millions of Americans are forced to choose between paying for medications they need to live or paying for food, rent, and other basic necessities. Those days are ending.”<br /> <br /> Big Pharma, as Biden alluded to, is naturally not so giddy about this news. In fact, the pharmaceutical industry has been hellbent on hindering such efforts, recently filing eight lawsuits in federal courts across the U.S. declaring the program unconstitutional. However, as has been the consensus among legal experts, the Biden administration has opined that there is no provision in the U.S. Constitution that prevents it from negotiating medication prices.<br /> <span style="letter-spacing:.3pt"><br /> “The Biden-Harris Administration isn’t letting anything get in our way of delivering lower drug costs for Americans,” Secretary of Health and Human Services Xavier Becerra said in a statement back in June. “Pharmaceutical companies have made record profits for decades. Now they’re lining up to block this administration’s work to negotiate for better drug prices for our families. We won’t be deterred.”</span><br /> <br /> If pharma companies opt not to comply with the process, they will have to pay an excise tax of up to 95% of <span style="letter-spacing:.3pt">the medications’ U.S. sales or remove all their products from the Medicare and Medicaid markets. Some in the pharmaceutical industry contend that many of the medications on the list already have large rebates and discounts due to negotiations that currently occur in Part D insurance plans while others predict that the actual penalty will run as high as 1,900% of sales. And, of course, this program will not subside in 2026: per the </span>Inflation Reduction Act, the federal government can choose up to fifteen more drugs for negotiation in 2027, another fifteen drugs for 2028, and as many as 20 more drugs each year thereafter.<br /> <br /> But Biden has made it abundantly clear that he is not backing down against Big Pharma. After all, taking on Big Pharma is central to his larger “Bidenomics” vision of rebuilding the American economy from the middle out and the bottom up.<br /> <br /> “Let me be clear: I am not backing down,” Biden said on the morning of the major unveiling. “There is no reason why Americans should be forced to pay more than any developed nation for life-saving prescriptions just to pad Big Pharma’s pockets.”<br /> <br /> But Big Pharma, and its supporters such as </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#333333">lobby group Pharmaceutical Research and Manufacturers of America (PhRMA), don’t see it that way. They see the drug repricing program as the U.S. government having unfettered power, which they say would, in effect, stymie innovation in medical research and development.<br /> <br /> As Ameet Sarpatwari, an assistant professor at Harvard Medical School, told NPR following the August 29 announcement, “This is going to be a heavyweight battle.”</span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></p> 1272Wegovy: The Heart of the Matterhttps://www.phiagroup.com/Media/Posts/PostId/1270/wegovy-the-heart-of-the-matterBlog,Health Insurance,Healthcare Costs,Hospital BillsFri, 18 Aug 2023 13:15:29 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">By: David Ostrowsky </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment?</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">On August 8, Novo Nordisk, the Danish pharmaceutical juggernaut, unveiled the intriguing results of a large-scale clinical study documenting the efficacy of its obesity drug called Wegovy: of the nearly 18,000 participants aged 45 years or older suffering from both obesity and cardiovascular disease, 20 percent were found less likely to suffer from further heart disease and stroke symptoms after taking Wegovy. Perhaps, as the results indicated, obesity drugs such as Wegovy do not merely help patients shed weight but also deliver other long-term health benefits. The five-year trial was the first to demonstrate that an obesity drug could trigger lasting benefits to cardiovascular health for patients who are overweight but do not necessarily have diabetes. </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">So, now the question becomes will such promising results make more insurers feel inclined to provide coverage for a drug that costs $1,349 a month and whose documented benefits have yet to be chronicled in a peer-reviewed or medical journal? </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">(Novo has said it plans to present the results at a conference later this year.) <span style="background:white"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">“It’s going to make it much harder to deny coverage and not pay for these products for a non-diabetic population,” noted Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management, in the August 8 edition of the <i>New York Times</i>. “It’s going to make it very difficult to make the argument that this isn’t part of an essential health benefit when there are cardiovascular benefits.” </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">It's undeniable that Wegovy has potential for delivering profound benefits for those afflicted with heart disease, which remains the deadliest – not to mention costliest – malady in America. Consider that the study’s reported 20 percent lower incidence of heart attack was considerably higher than the 15-17 percent range anticipated by investors and industry analysts. Also, it’s not as though Novo Nordisk is an unproven entity in the world of pharma. </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Another version of a weight loss drug manufactured by Novo Nordisk, Ozempic, has been approved for reducing blood sugar levels in adults with type 2 diabetes and has been found to lower the risk of heart complications in diabetic patients. <span style="background:white"></span></span></span></span></span></span></span></p> <p class="css-at9mc1" style="margin:0in; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span style="vertical-align:baseline"><span style="font-family:"Times New Roman",serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">But there’s still murkiness surrounding the findings and legitimate questions as to whether insurance companies will see direct cost savings by covering the medication. </span></span></span></span></span><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Novo Nordisk posited that Wegovy reduced the overall risk of heart attacks, strokes and cardiovascular deaths by 20 percent, but the company failed to categorize the effects of the drug on each of those outcomes individually.<span style="background:white"><span style="color:black"> Meanwhile, Novo Nordisk also did not detail how much weight patients lost or provide details on side effects of the drug (reportedly, patients have reported experiencing nausea, diarrhea, vomiting, constipation and stomach pain) that may have deterred a sizable number of patients from completing the trials. </span></span><span style="background:white"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">On another level, though, perhaps due to the well-publicized favorable results stemming from the Wegovy clinical trials, there will be a shift in how mainstream society – and not just the medical field – perceives obesity. Perhaps, this recent development – the emergence of widely accepted empirical evidence proving obesity is a biological condition that can be treated with a medical remedy – will move the needle in making the epidemic less stigmatized.</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></span></span></p> <p class="css-at9mc1" style="text-align:justify; margin-right:0in; margin-left:0in"><span style="font-size:12pt"><span style="background:white"><span style="vertical-align:baseline"><span style="font-family:"Times New Roman",serif"><span style="background:white"><span style="color:black">As </span></span><span style="color:black">Dr. Ania Jastreboff, an endocrinologist and obesity-medicine specialist at Yale University, was quoted as saying<span style="background:white"> in the aforementioned August 8 <i>New York Times</i> article, </span>“Obesity’s not a personal choice <span style="background:white">–</span> it’s not behavioral, it’s not something that people choose. Medications like this, we believe, are potentially treating that underlying biology.”</span></span></span></span></span></p> 1270The Power Dynamics of Gag Clauseshttps://www.phiagroup.com/Media/Posts/PostId/1267/the-power-dynamics-of-gag-clausesBlog,Health Insurance,Healthcare Costs,Self FundingMon, 14 Aug 2023 14:23:09 GMT<p style="text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:">By: Jon Jablon, Esq. </span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights are immense, and it’s worth looking into the power dynamics at play since it’s not quite as simple as saying that plans can no longer have these gag clauses.</span><br /> <b><span style="font-size:12.0pt"><br /> A Brief History: The Emergence of Gag Clauses</span></b></span></span><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> <br /> Per the Consolidated Appropriations Act 2021, the now-impermissible “gag clauses” are contractual terms that tend to prohibit health plans from receiving or disclosing specific information about providers, particularly relating to the cost or quality of care. Historically, health plans and their vendors could, and often did, freely enter into agreements that included gag clauses. This secrecy has been an unfortunate staple of the self-funded industry, and has played a part in preventing many health plans and plan participants from truly understanding (and, sometimes, presented a barrier to compliance with) their contractual obligations.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> While the intention of the gag clause prohibition is to foster transparency and consumer protection, the introduction and enforcement of the prohibition has raised some eyebrows, particularly concerning the balance of power in the self-funded health insurance industry. In particular, many are less than thrilled that the onus is placed on the health plan to avoid agreeing to gag clauses rather than, for instance, the onus being placed on a vendor with far greater bargaining power to avoid attempting to impose gag clauses to begin with.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> Bargaining Power and The Shadows of Big Players</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> Larger entities, most predominantly vast national PPO networks that so many health plans and TPAs ally with, possess inequitably-high bargaining power, given their relative ubiquity. Leaving aside the talking point that these national networks provide relatively little cost-containment value for health plans, instead offering prohibition on balance billing (which is certainly valuable, but not in the cost-containment context) alongside discounts so small as to be virtually meaningless in many cases, their geographic and market dominance allows them to set terms that are favorable to them and their contracted providers, often sidelining transparency, and often intentionally. What we’ve seen is that the larger the entity, the more likely it is to use gag clauses as strategic tools to maintain their market stronghold.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> Inequity in the Requirement: <i>Why Health Plan</i>s?</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> The statutory prohibition on gag clauses is placed squarely on health plans, which presents an inherent and undeniable bias. Surely Congress knows that it’s <i>not</i> health plans, but their vendors, that impose these clauses; these vendors push for such clauses to safeguard their interests, keeping cost structures and quality metrics under wraps specifically to quash transparency. Health plans are the unfortunate victims of this power imbalance and therefore gag clauses, not the perpetrators.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> In light of that, putting the onus solely on health plans seems a bit unjust, effectively holding a health plan accountable for a provision that a given health plan very likely didn't <i>want,</i> but had no choice but to accept due to the power dynamics at play. Lest we forget, too, that even given this gag clause prohibition, <i>vendors</i> are certainly not prohibited from attempting to demand the continued existence of gag clauses; vendors remain free to make demands, and the prohibition on gag clauses does not extend to a vendor – but health plans prohibited from <i>accepting</i> those gag clauses. Placing this limitation on health plans sidesteps the real culprits that do actually promote gag clauses, and we continue to see vendors trying to put a wolf in sheep’s clothing by trying to promote not-quite-so-obvious gag clauses, but gag clauses nonetheless.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> Crossroads for TPAs</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> As they so often are, TPAs are caught in the whirlwind of all this. As with so many other aspects of their business, TPAs must walk a tightrope between providing comprehensive assistance to health plans and increasing their workload and responsibility. To pile on more confusion, many employer groups simply expect their TPAs to handle the discovery of gag clauses, attestation of whether there are gag clauses, and future avoidance of gag clauses as part of their normal business, which can lead to some awkward conversations.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><br /> A Call for a More Balanced Approach & Support</span></b></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> Though the gag clause prohibition (and the resultant requirement to attest to whether or not there are currently any gag clauses in place) is a tangible issue that TPAs, health plans, and other players in the industry need to proactively deal with, the prohibition itself offers a window into the larger power imbalances in the self-funded marketplace, and the perhaps somewhat misguided . As regulations evolve, we sincerely hope that the powers that be recognize the urgent need to more evenly balance this power, ensuring that health plans are not unduly burdened, nor vendors given a free pass.</span></span></span><br /> <span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><br /> The American healthcare system is as much about patient well-being as it is about business dynamics (though some might say that business dynamics are more prominent in many ways). As the various stakeholders navigate these murky waters, a holistic approach that considers the roles and influences of all entities, big or small, is crucial, and we hope that Congress eventually agrees. For now, though, health plans have a tough road ahead. </span></span></span><br /> <b><i><span style="font-size:12.0pt"><span calibri="" style="font-family:"><br /> Please don’t forget that The Phia Group is here to help! ICE clients, don’t hesitate to use your dedicated ICE inbox for gag clause-related support at no additional cost. Others needing support can reach out to <a href="mailto:PGCReferral@phiagroup.com" style="color:#0563c1; text-decoration:underline">PGCReferral@phiagroup.com</a> for assistance.</span></span></i></b></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin-left:.5in; margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"></span></b></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> 1267Expanding Protections for Breastfeeding Mothershttps://www.phiagroup.com/Media/Posts/PostId/1265/expanding-protections-for-breastfeeding-mothersBlog,Affordable Care Act,Health Insurance,PlanThu, 03 Aug 2023 19:55:52 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Kendall Jackson </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">So far this year, we have seen two notable advancements in protections for breastfeeding mothers in the workplace. The first of which includes the expansion of women’s preventive services under the Affordable Care Act (ACA). Based on new recommendations by the Health Resources and Services Administration (HRSA), breastfeeding mothers will no longer have to pay out-of-pocket costs for particular breast pumps and related supplies. The HRSA specifically noted that access to double electric breast pumps should be prioritized and should not be treated as a secondary step if manual pumps are unsuccessful. In addition to the double electric breast pumps, the preventive service recommendation includes coverage for the pump parts, maintenance of the pumps, and supplementary equipment for women needing additional services or for women who have faced breastfeeding complications. Plans subject to the ACA and its preventive care mandate must cover these new additions to women’s preventive services with no cost sharing.</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The second protection is an employment law that governs nursing mothers’ access to areas to express breast milk while at work. The Providing Urgent Maternal Protections (PUMP) For Nursing Mothers Act expanded the Fair Labor Standards Act (FLSA) and took effect on April 28, 2023. Under the PUMP Act, for one year following the birth of the child, the nursing mother must be allowed to take a break for a reasonable time to express breast milk. The frequency and duration of the breaks are dependent on the mother’s needs. Additionally, the employer must provide a space for the nursing mother to pump that is not a bathroom, is shielded from view, and will not expose the mother to the intruding staff or public. Employers are not required to compensate the mothers during this break unless the mother is not fully relieved from work duties or if the break would have otherwise been paid. The PUMP Act applies to all employers with 50 or more employees. If an employer with fewer than 50 employees can demonstrate that adhering to the requirements of the Act would impose undue hardship on the employer, then the employer would be exempt from the Act’s requirements. Currently, flight attendants and pilots are the only occupations excluded from the Act.</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">With any new development in law, it is important to know how it will affect the employer and their plan. The new preventive service recommendation for breastfeeding mothers specifically impacts coverage for health plans that are subject to the ACA. The PUMP Act, meanwhile, is an employment law which directly impacts the employer. If applicable, employers must provide breaks for nursing mothers according to the standards set out in the Act. As always, please do not hesitate to reach out to our consulting teams to assist with any questions you may have relating to these expanded protections for mothers in the workplace. </span></span></span></span></span></span></p> 1265Diapers & Wipes Reflectionhttps://www.phiagroup.com/Media/Posts/PostId/1264/diapers-wipes-reflectionBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 03 Aug 2023 13:57:29 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#595959">By: Desireé Erskine</span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#595959"></span></span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#595959">My name is Desireé Erskine and I have been at The Phia Group for the past 17 years, the last 10 of which I have spent as an Overpayment Recovery Specialist in the Provider Relations Department. </span></span></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">As my family and I look forward to celebrating our daughter Kinsley’s first birthday this Sunday, we have revisited some of our fond memories and challenges in our first year as a family of five. In doing so, we have discussed how helpful Phia’s “Diapers and Wipes” program has been to our family. </span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The “Diapers and Wipes” program, per The Phia Group’s handbook:</span></span></span></span></span></p> <p style="text-align: justify; margin: 0in 0in 8pt 40px;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">If a Plan Participant is pregnant and expecting the birth of a child, they can choose to seek prenatal, neonatal and/or childbirth services from any number of in-network providers identified as leaders in both quality of care and fair pricing. After consulting with HR, if a Plan Participant chooses to utilize one of those identified providers for childbirth services, that Plan Participant will receive $300 per month to use on diapers and wipes (via a gift certificate and facilitated by creating an auto-ship account).</span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Some personal backstory: On the second day following her birth, Kinsley started breaking out in an area that was covered by the diaper. I suspected it was due to an allergy to formula as I had to supplement while in the hospital. I immediately stopped the formula and waited a few days to see if this would start to clear up. It did not. In fact, it had gotten progressively worse and went downhill quickly. </span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">After several calls, trips, and visits, we were referred to the Boston Children’s Hospital Dermatology Program. We were told Kinsley had an ulcerating hemangioma. This hemangioma grew in diameter and burrowed deep, becoming full-blown by the time she was two weeks. It was approximately the size of a golf ball cut in half. Doctors have found that the most successful way to treat this is with a BP medication. With the dose she needed, Kinsley had to be monitored closely; after a few weeks of increasing the dose on our own, the doctors thought it would be best to have her admitted on an inpatient basis. She and I spent a few days at Children’s so that she could be watched. After passing her “test,” she was sent home with medication to be taken twice daily, along with numbing ointments. </span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">I am happy to say after a year of monthly doctor’s appointments, dose increases, topicals, medication taken twice a day, and quite a few DIAPERS – we are <i>almost</i> in the clear. Fortunately! </span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">For a second though, just imagine an open sore in the diaper region of an infant. This was painful and tiresome, for her and for us. This is where the Diapers and Wipes program has helped our family tremendously. As we all know, infants are changed often, for obvious reasons. Between her bathroom breaks and all the creams we needed, we had to “over change” her. She needed a clean and dry diaper constantly. So, the very generous $300 a month stipend for diapers and wipes relieved our family of an incredible financial burden. One we would have had if we did not participate in this program. </span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">We are beyond grateful for the financial support that Phia has provided. If you are looking to expand your family (congrats!), I highly encourage you to look into this program more and ask questions if needed. It has saved us in more ways than one.</span></span></span></span></span></p> <p style="margin-bottom:0in; text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Thank you Adam & OPCOM for the help this past year and for providing this program! I am extremely grateful to be a part of such a great company!</span></span></span></span></span></p> 1264